"hospital_name","last_updated_on","version","location_name","hospital_address","type_2_npi","license_number|CA","To the best of its knowledge and belief, this 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 in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","attester_name"
"Northbay Medical Center","2026-04-01","3.0.0","Northbay Medical Center|Northbay Health VacaValley Hospital","1200 B  Gale Wilson Blvd, Fairfield, CA 94533|1000 Nut Tree Rd, Vacaville, CA 95687","1821147786","110000093","true","Josephe D'Angina"
"description","code|1","code|1|type","code|2","code|2|type","code|3","code|3|type","code|4","code|4|type","billing_class","setting","drug_unit_of_measurement","drug_type_of_measurement","modifiers","standard_charge|gross","standard_charge|discounted_cash","payer_name","plan_name","standard_charge|negotiated_dollar","standard_charge|negotiated_percentage","standard_charge|negotiated_algorithm","median_amount","10th_percentile","90th_percentile","count","standard_charge|methodology","standard_charge|min","standard_charge|max","additional_generic_notes"
"Professional Component","","","","","","","","","facility","both","","","26","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Professional Component","","","","","","","","","facility","both","","","26","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Bilateral Procedure","","","","","","","","","facility","both","","","50","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Distinct Procedural Service","","","","","","","","","facility","both","","","59","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional","","","","","","","","","facility","both","","","76","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Reference (Outside) Laboratory","","","","","","","","","facility","both","","","90","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","","","","","","","","","facility","both","","","95","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, second digit","","","","","","","","","facility","both","","","F1","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, third digit","","","","","","","","","facility","both","","","F2","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fourth digit","","","","","","","","","facility","both","","","F3","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, fifth digit","","","","","","","","","facility","both","","","F4","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, thumb","","","","","","","","","facility","both","","","F5","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, second digit","","","","","","","","","facility","both","","","F6","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, third digit","","","","","","","","","facility","both","","","F7","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fourth digit","","","","","","","","","facility","both","","","F8","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right hand, fifth digit","","","","","","","","","facility","both","","","F9","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left hand, thumb","","","","","","","","","facility","both","","","FA","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient speech language pathology plan of care","","","","","","","","","facility","both","","","GN","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient occupational therapy plan of care","","","","","","","","","facility","both","","","GO","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Services delivered under an outpatient physical therapy plan of care","","","","","","","","","facility","both","","","GP","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Skin substitute used as a graft","","","","","","","","","facility","both","","","JC","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Requirements specified in the medical policy have been met","","","","","","","","","facility","both","","","KX","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left circumflex coronary artery","","","","","","","","","facility","both","","","LC","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left anterior descending coronary artery","","","","","","","","","facility","both","","","LD","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left main coronary artery","","","","","","","","","facility","both","","","LM","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left side (used to identify procedures performed on the left side of the body)","","","","","","","","","facility","both","","","LT","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Investigational clinical service provided in a clinical research study that is in an approved clinical research study","","","","","","","","","facility","both","","","Q0","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Clia waived test","","","","","","","","","facility","both","","","QW","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right coronary artery","","","","","","","","","facility","both","","","RC","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Ramus intermedius coronary artery","","","","","","","","","facility","both","","","RI","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right side (used to identify procedures performed on the right side of the body)","","","","","","","","","facility","both","","","RT","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"State supplied vaccine","","","","","","","","","facility","both","","","SL","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, second digit","","","","","","","","","facility","both","","","T1","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, third digit","","","","","","","","","facility","both","","","T2","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fourth digit","","","","","","","","","facility","both","","","T3","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, fifth digit","","","","","","","","","facility","both","","","T4","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, great toe","","","","","","","","","facility","both","","","T5","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, second digit","","","","","","","","","facility","both","","","T6","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, third digit","","","","","","","","","facility","both","","","T7","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fourth digit","","","","","","","","","facility","both","","","T8","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Right foot, fifth digit","","","","","","","","","facility","both","","","T9","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Left foot, great toe","","","","","","","","","facility","both","","","TA","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","","","","","","","","","facility","both","","","TC","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Aetna","HMO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Aetna","PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Cross","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Cross","Anthem Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Cross - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Shield","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Shield","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Blue Shield - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Cigna","HMO/PPO","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","First Health/Coventry","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","HealthNet","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","HealthNet","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","HealthSmart/Interplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Humana","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Kaiser","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Kaiser","Radiation Therapy All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Multiplan","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Partnership","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Partnership - ASC","Medicaid Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","PHCS","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","Sutter Health Plus","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","UnitedHealthCare","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","UnitedHealthCare","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","UnitedHealthCare - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","WHA","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","WHA","Medicare Managed Care Plan","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","WHA - ASC","All Commercial Plans","","","","","","","","","","","The modified price is presented in the standard charge value."
"Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy.","","","","","","","","","facility","both","","","ZL","","","WHA - ASC","Capitated","","","","","","","","","","","The modified price is presented in the standard charge value."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","155.73","30","261.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","26.87","26.87","26.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","35.85","18.75","35.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","399.38","399.38","399.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Naltrexone, depot form","0759","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76713","76713","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","140974.75","140974.75","140974.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","90943.85","90943.85","90943.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2373.07","2347.53","3376.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, bupivacaine liposome","0763","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","122.02","122.02","122.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","182.53","87.25","338.65","62","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","134.06","35","203.47","191","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","96.45","53.98","358.73","54","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","158.97","15","166.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","196.97","30.47","343.63","128","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","142.06","103.5","212.78","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","144","80","144","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","225.48","208.38","288.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","86.6","86.6","86.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","269.84","269.84","269.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","114.84","42.47","275.58","206","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","176.57","55","288.82","65","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","148.79","55","237.35","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","148.02","50","203.38","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ketorolac tromethamine inj","0764","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","194.61","50","309.96","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","168.51","92.14","261.04","102","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","140.84","30","229.54","73","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","116.21","15","199.84","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","206.98","40","332.2","82","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","172.21","144.91","199.9","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","50","50","50","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","30","30","30","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","223.83","223.83","223.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","173.35","84.71","232.91","308","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","140","140","140","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","197.7","10","331.1","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","40","10","216.66","77","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","184.64","15","190.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred acetate 1 mg","0790","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","3.85","3.85","3.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, glycopyrrolate, 0.1 mg","0792","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1358.48","1358.48","1358.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","36.56","34.69","1408.12","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate","0800","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","237.24","113.88","418.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","150.23","112.05","257.63","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","139.81","139.81","139.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","142.43","65.71","209.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","204.26","204.26","204.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","288.93","287.88","288.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","118.69","35.85","118.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","204.95","183.12","260.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","237.73","166.54","237.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, methylpred sod succ 5mg","0801","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","4881.23","4881.23","4881.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1250.75","1250.75","1250.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Hiv prep, inj, cabotegravir","0805","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","65.04","65.04","65.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","153.71","153.71","153.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","479.02","479.02","479.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","562.19","562.19","562.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","89.29","89.29","213.88","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","84.55","84.55","84.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10","10","503.31","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","570.56","570.56","570.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Synvisc or synvisc-one","0874","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","277.74","277.74","280.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","234.45","35","431.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","179.21","86.34","273.55","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","81.72","81.72","298.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","337.67","337.67","457.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","245.27","89.29","319.66","82","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","50.04","10","120.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10","10","145.99","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Euflexxa inj per dose","0875","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","348.34","348.34","348.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","92.79","92.79","92.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Orthovisc inj per dose","0877","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","1692.67","1534","1733.67","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1449.6","1159.68","2328.56","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1412.62","159.47","2046.72","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","197.8","197.8","1476.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1806.78","169.69","3552.78","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","471.8","471.8","471.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","1511.48","1511.48","1511.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1601.18","306.98","1601.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1478.62","202.55","2136.92","338","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","451.28","451.28","451.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1554.86","216.51","2216.05","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1565.05","131.58","1574.85","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1664.01","1658.09","1741.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection,onabotulinumtoxinA","0902","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","494.19","494.19","494.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj iron dextran","1237","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","359.53","353.23","478.24","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","905.28","905.28","905.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","373.55","373.55","381.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","284.75","284.75","284.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Degarelix injection","1296","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2.17","2.17","2.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj vedolizumab iv 1 mg","1489","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","50.73","50.73","70.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","212.8","189.86","212.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Penicillin g benzathine inj","1829","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","35628.11","35628.11","35628.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","4543.93","4543.93","4543.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, inflectra","1847","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","952.68","952.68","952.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Suprt dev, a-v fistula, imp","2049","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","6.52","4.2","104.19","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","114.72","6.58","198.8","144","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.51","188.51","188.51","233","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","188.51","188.51","188.51","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","32.75","4.6","238.73","70","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","125.98","8.64","217.5","61","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","15","15","189.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","261.4","261.4","261.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","188.51","188.51","188.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","74.4","74.4","74.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","128","57.6","128","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","136.4","74.4","145.25","2159","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","35","35","35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","170.51","71.67","210.18","119","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.52","10","198.51","215","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","15","15","15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinic Visits and Related Services","5012","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","370.94","259.91","509.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","377.72","246.65","430.08","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","365.14","365.14","365.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","44.45","40.6","128.8","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","130.1","130.1","130.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","425.18","198.4","2097.51","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","524.16","191.91","985.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","331.02","331.02","331.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1872.5","1872.5","1872.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","302.4","182.55","2698.49","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","198.4","198.4","205.89","687","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","386.25","363.77","413.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","115.45","40.6","131.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","235.2","235.2","235.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Type A ED Visits","5021","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","1329.7","1050.26","2987.19","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1100.96","655.46","2481.42","179","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","143.45","143.45","233.45","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","167.95","98.3","1853.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1264.14","900.63","2733.71","88","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1533.48","836.83","5455","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","1408.63","1408.63","2356.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1735.97","1245.88","2675","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","234.45","234.45","234.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","1518.95","1518.95","1518.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","416.29","416.29","416.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","867.34","140.22","1764.4","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","139.88","139.88","243.16","2374","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","1668.91","1521.1","2437.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1100.76","528.41","2349.14","66","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","143.45","109.15","234.15","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","475.45","150","787.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Type A ED Visits","5022","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","1852.8","1852.8","1852.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3661.59","2343.08","5631.38","157","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","3021.92","1346.2","4836.47","736","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","316.83","316.83","472.39","267","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","405.03","341.33","561.59","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","3509.91","2259.11","5682.24","411","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","4052.76","1308.04","7185.52","116","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","438.88","340","3972.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","2675","2047.04","2870.11","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","411.68","385.44","2675","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","2464.07","2464.07","2464.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","297.23","282.53","562.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","2285.95","258.98","3448.31","259","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","1765.17","1765.17","1765.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","1500","1500","1500","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","264.58","198.4","475.46","10038","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","5107.65","3796.95","9613.59","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","3225.14","1342.35","5155.13","281","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","356.04","282.53","467.7","196","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1500.12","93.35","1745.49","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Type A ED Visits","5023","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","9135.74","7616.02","22031.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","8359.77","3875.45","15947.71","217","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","6633.95","3642.4","12201.72","806","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","779.45","534.69","1365.3","310","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","902.37","549.39","1195.69","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","8016.13","5189.8","16203.23","502","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","8789.39","3279.37","22370.72","134","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","300","300","602.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","4707.45","2592.56","8147.72","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","614.49","376.17","1464.93","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","843.57","625.14","1073.06","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","5550.34","2000","11307.15","256","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","2406.23","2406.23","2406.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","466.33","267.59","1155.82","7388","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","149.75","149.75","149.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","10072.5","8126.36","26104.61","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","7149.59","3065.45","15421.89","310","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","780.95","534.69","1382.42","308","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1700","128.37","1800","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Type A ED Visits","5024","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","10261.96","7783.79","15132.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","13740.57","7955.16","27744.15","191","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","11120.31","6547.52","22431","650","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","20192.76","20192.76","20192.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1340.39","937.45","3796.47","373","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1266.13","898.35","4086.07","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","13777.12","8771.6","31600.03","429","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","13741.04","8287.02","37499.42","114","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","50","50","1120.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","7982.29","2625","19307.81","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1250.85","901.57","6770.18","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","32171.21","32171.21","32171.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1366.91","918.34","2242.42","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","10181.54","6058.03","17943.44","266","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","4847.96","4847.96","4847.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","897.07","373.36","2155.7","4924","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","4241.59","4241.59","4241.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","18240.4","13501.49","32968.94","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","12082.5","7362.13","21150","339","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1421.49","929.91","4011.41","483","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1750","1425.56","1828.37","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Type A ED Visits","5025","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","7381.38","7381.38","7381.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","20992.42","13108.32","54145.35","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","20497.17","11187.02","53783.33","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3974.32","1452.58","9001.11","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1999.18","1617.12","3873.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","33762.75","17171.14","61670.08","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","26810.7","14795.47","58782.5","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","18108.39","17913.6","23249.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10932.14","10932.14","10932.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","17463.57","9066.84","41422.18","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1708.21","946.17","4599.98","580","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","22957.02","13729.56","34827.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","19052.95","9840.55","55000","29","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3948.75","1558.06","9796.23","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","2741","2741","2741","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Critical Care","5041","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","50876.54","50876.54","57526.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7507.51","7507.51","7507.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","50865.56","50865.56","50865.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","45112.06","36046.19","47288.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","6389.42","4159.41","8612.84","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","21150","21150","21150","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Trauma Response with Critical Care","5045","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","213.9","138.9","2582.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","260.5","207.62","677.06","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","290.66","232.52","772.94","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","189.47","189.47","189.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","241.94","214.48","472.05","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","170.54","158.18","3292.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","385.11","385.11","385.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","3082.34","3082.34","3082.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","151.4","32.21","276.01","204","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","290.66","290.66","290.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","469.38","188.52","479.38","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Skin Procedures","5051","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","83.73","38.85","3028.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","212.25","1.25","4501.07","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","772.94","584.43","772.94","60","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","772.94","579.7","772.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","92.85","14.82","2059.6","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","309","276","487.39","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","47.57","14.51","165.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","65.6","36.35","284.72","464","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","365.99","316.04","4070","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","584.43","521.08","788.44","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Skin Procedures","5052","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","75353.26","75353.26","75353.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1083.94","1083.94","1083.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","659.47","659.47","953.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","727.48","727.48","727.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","480.22","179.68","1774.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","8009.85","8009.85","8009.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1127.09","1127.09","1127.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Skin Procedures","5053","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","851.71","851.71","1843.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2864.32","188.51","3156.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","137051.2","137051.2","137051.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","182.52","143.16","641.4","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2968.03","2675.81","3243.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Skin Procedures","5054","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","91295.76","91295.76","91295.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","448","448","448","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Skin Procedures","5055","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","4632.14","4632.14","4632.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","3731.01","1112.24","21886.15","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1020.22","514.61","8905.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1029.22","1029.22","1029.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6933.59","5538.66","115860.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","7757.1","5300.88","8652.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","220.89","197.72","621.51","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","2895","2754.31","4075.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1031.22","275","7671","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Excision/ Biopsy/ Incision and Drainage","5071","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","12624.2","7794.49","96685.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","6190.97","648.93","59825.38","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2370.1","2370.1","9067.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2370.1","2370.1","2372.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","8126.72","1235.57","72144.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","104826.4","104826.4","104826.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2232.9","2232.9","2232.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","588.61","232.63","1636.22","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","8990.75","5747.04","19673.05","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2375.6","275","13861.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Excision/ Biopsy/ Incision and Drainage","5072","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","106791.8","106791.8","148356.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","71545.47","48556.98","126733.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1566.9","1371.12","24833.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","10030.07","10030.07","10030.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1762.05","1666.08","108264.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","115170.93","115170.93","115170.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","1210.76","1210.76","1210.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","965.62","601.62","1383.84","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","51541.25","3129.28","87657.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4267.03","1715.91","7831.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Excision/ Biopsy/ Incision and Drainage","5073","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","117026.34","117026.34","117026.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76713","76713","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16225.5","16225.5","16225.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","18879.15","18879.15","18879.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","188669.35","188669.35","188669.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","152934.74","152934.74","152934.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","57684.19","57684.19","57684.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2143.29","1402.58","3677.4","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","18786.85","18786.85","18786.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Breast/Lymphatic Surgery and Related Procedures","5091","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","239435.82","239435.82","239435.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","11400","11400","11400","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","299741.69","299741.69","299741.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2056.94","1489.25","4295.45","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","129372.84","129372.84","129372.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","275","275","275","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Breast/Lymphatic Surgery and Related Procedures","5092","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1945.79","1945.79","2822.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Breast/Lymphatic Surgery and Related Procedures","5093","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","432373.68","432373.68","432373.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","11400","11400","11400","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","246300.71","246300.71","246300.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","4714.75","4371.96","5546.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","275","275","275","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Breast/Lymphatic Surgery and Related Procedures","5094","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","231.32","231.32","256.32","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","230.82","230.82","230.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","197.72","178.31","198.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","1629.29","1629.29","1629.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","180.09","43.69","208.85","111","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","419.31","419.31","419.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Strapping and Cast Application","5101","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1817.68","1817.68","1817.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","14192.43","14192.43","14192.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","4483.35","4483.35","4483.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","162.83","139.88","1438.16","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Musculoskeletal Procedures","5111","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3673.19","3673.19","3673.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2219.75","577","76527.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1202.12","956.32","2341.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1292.42","1292.42","2342.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6742.16","1762.8","20516.23","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","20813.05","9764.42","125099.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","7674.75","7674.75","7674.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","727.73","529.91","1476.72","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","5288.31","175","7292.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1198.9","1198.9","2292.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1700","1700","1700","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Musculoskeletal Procedures","5112","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","57512.84","5687.15","189334.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2614","331","76693","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4114.37","4114.37","8189.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","11693.94","11693.94","11693.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2300.23","1762.8","98982.86","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1957.88","1957.88","1957.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","100","100","100","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","836.12","332.5","1506.16","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","6108.51","3641","86542.45","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7033.6","100","12379.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","100","100","100","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Musculoskeletal Procedures","5113","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","16488.16","4311.15","116003.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","6187","272.53","76713","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","17528.56","17528.56","17528.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","21841.94","21841.94","21841.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","4197.62","1705.6","145556.56","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","139614.25","94734.28","176366.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1151.12","630","2212.21","81","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","11302.36","4474","134520.68","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6132.4","175","22212.11","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Musculoskeletal Procedures","5114","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","153658.98","153658.98","203873.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76276.58","11399.99","76713","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","19235.35","15169.79","24205.57","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","25355.99","25355.99","25355.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","161486.98","145680.61","201293.77","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","133315.96","133315.96","173871.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","20392.49","20392.49","20392.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2237.55","1708.68","3764.17","80","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","133817.77","15380.1","135000","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","20618.38","275","30516.41","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1688.87","1688.87","1688.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Musculoskeletal Procedures","5115","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","171661.13","171661.13","171661.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","11400","9120","76713.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","24657.92","24657.92","24657.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","26918.62","26918.62","26918.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","218514.24","218514.24","259469.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2798.2","2169.26","6430.26","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","28396.65","28396.65","28396.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Musculoskeletal Procedures","5116","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","18065.53","18065.53","18065.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","399.09","399.09","399.09","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Airway Endoscopy","5151","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","32035.27","32035.27","32035.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1072.94","255.78","5059.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Airway Endoscopy","5153","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","66315.92","66315.92","66315.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","14527.4","14527.4","14527.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","109613.15","109613.15","109613.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1139.89","1113.61","2371.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5870.68","5127.64","11395.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Airway Endoscopy","5154","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","77316","77316","77316","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1483.95","1414.44","3124.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","135000","135000","135000","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Airway Endoscopy","5155","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1173","1173","1173","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1400.39","1400.39","1400.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","500","175","1003.62","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ENT Procedures","5161","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2060.18","1795.23","3577.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","363.4","319.14","2925.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ENT Procedures","5162","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","59422.64","59422.64","59422.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1711.84","1711.84","1711.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1653.71","1653.71","1653.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 ENT Procedures","5163","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2587","2587","75611.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","106406.17","99892.12","106925.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","5571.3","5571.3","5571.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1302.01","1049.96","3538.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 ENT Procedures","5164","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","100670.14","100670.14","161198.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","72180.18","53384.24","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","15350.17","15350.17","15350.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2644.2","2644.2","2644.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1263.7","731.12","1680.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","83785.7","83785.7","83785.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","275","275","275","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 ENT Procedures","5165","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","4310.88","2492.56","5205.6","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","874.99","874.99","874.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1115.2","1115.2","1115.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","212.21","136.4","3155.33","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4477.93","4477.93","4477.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Vascular Procedures","5181","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","79557.94","79557.94","79557.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","45159.64","45159.64","73780.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2029.96","1817.91","2272.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2283.98","2283.98","2283.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","9349.73","9349.73","16315.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","9881.28","9881.28","9881.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","637.29","506.82","1427.1","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2273.39","2273.39","2273.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Vascular Procedures","5182","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","78002.68","78002.68","78002.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","26491.21","1227.64","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6801.75","4604.19","18263.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4608.04","4608.04","4608.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","24759.83","24290.24","32918.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","28272.7","28272.7","33819.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4604.19","4604.19","4604.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","77584.11","77584.11","77584.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1030.23","787.69","2126.87","58","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","22810.35","21278.26","23233.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","4515.99","1609.77","8301.41","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Vascular Procedures","5183","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","69547.01","69547.01","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","18573.16","18573.16","18573.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","85381.71","85381.71","85381.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1462.95","1278.99","1701.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11923.45","10754.67","15031.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Vascular Procedures","5184","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","77587.32","77587.32","77587.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76688.94","66961.69","76963","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8272.43","7909.81","9434.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","72490.65","53403.07","94494.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","107074.58","107074.58","107074.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","3156.89","2477.53","5050.91","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","44969.06","7640.64","74975.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9609.34","6690.62","11756.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Endovascular Procedures","5191","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","37602.75","37602.75","37602.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3749.83","2999.87","8340.22","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6667.27","6667.27","59476","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5013.55","5013.55","5013.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","712.75","489.67","2202.75","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","4499.26","4499.26","4499.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6672.18","145.6","11563.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Endovascular Procedures","5192","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","43447.17","43447.17","43447.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","49486.93","49486.93","701142.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16589.07","7405.04","39144.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","16491.07","16491.07","16591.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","89527.89","89527.89","89527.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","100","100","100","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2155.59","1414.36","22491.91","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","65420.14","65420.14","65420.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16440.44","275","26651.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Endovascular Procedures","5193","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","35393.88","35393.88","35393.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","145204.3","145204.3","145204.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2756.48","1693.96","8590.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","103449.84","103449.84","103449.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","26272.71","21013.77","70602.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Endovascular Procedures","5194","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","8797.22","8797.22","8797.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Electrophysiologic Procedures","5212","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76713","34869.58","77200.87","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","35889.86","35889.86","35889.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","35891.86","35891.86","35891.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","169721.62","152667.09","223387.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","4436.93","1595.42","6847.5","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","133263.65","130364.13","135000","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Electrophysiologic Procedures","5213","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","16133.18","16133.18","16133.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pacemaker and Similar Procedures","5222","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","90558.3","90558.3","90558.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","14985.31","12485.21","15312.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","68510.29","68510.29","68510.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","67629.7","67629.7","67629.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2806.42","2735.38","6933.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","15308.76","15176.76","15314.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pacemaker and Similar Procedures","5223","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","6902.28","6902.28","6902.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 ICD and Similar Procedures","5231","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","41961.74","41961.74","41961.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","154944.41","154944.41","154944.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","7318.06","1607.36","11600.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","37736.9","37736.9","37736.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 ICD and Similar Procedures","5232","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","20919.77","20919.77","20919.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1166.34","1110.34","2865.22","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","996.23","996.23","3784.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2698.3","2698.3","2750.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","21166.61","12289.64","144403.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","21011.68","2333.18","39664.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","6899.15","6899.15","6899.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1452.1","1452.1","1452.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","58389.87","58389.87","58389.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","876.56","197.53","2157.29","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1021.64","1021.64","1021.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1443.26","817.87","2860.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Blood Product Exchange and Related Services","5241","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","8644.29","909.42","29538.12","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1173","250","30836.7","46","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","27907.55","27907.55","27907.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1066.82","574.26","1371.47","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","719.83","718.83","1068.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1627.96","1245.46","3355.45","54","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1786.05","1338.27","43213.75","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","2348","2348","2348","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","37635.88","37635.88","37635.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","549.47","281.51","899.58","333","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","25128.68","25128.68","25128.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","2622.67","905","5793.47","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","721.33","175","3146.82","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","443.02","443.02","443.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Upper GI Procedures","5301","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","11166.98","11166.98","11166.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","9920.4","1843.03","51891.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2223.02","1232.27","4767.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2780.78","2780.78","2780.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","36533.97","36533.97","55710.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","36210.07","1969","46645.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","841.39","720.63","2080.54","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","24578.98","18011.02","36255.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2042.49","175","5728.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Upper GI Procedures","5302","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5572.64","5572.64","5572.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","9408.22","9408.22","9408.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","37658.32","37658.32","37658.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1374.61","1271","2101.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Upper GI Procedures","5303","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","1971.75","1839.75","18021.38","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1173","1173","2346","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","697.99","697.99","1341.35","27","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","533.93","355.95","533.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1542.45","1089.36","1674.45","43","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","3450.07","1288.4","31400.89","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1144.74","858.55","2629","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","730.25","70","932.45","101","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1103.85","598","1526.29","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","697.99","697.99","1612.5","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","919.8","919.8","919.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Lower GI Procedures","5311","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3115.46","1692.29","17837.68","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1508.01","322","3017.6","95","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1247.6","902.6","2591.01","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1355.9","904.6","2313.68","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2047.59","1492.4","3558.6","104","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","11336.47","2015.16","37599.88","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1406.3","910.35","3725","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1353.9","1353.9","1353.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","701.9","531.97","960.12","235","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1426.78","477.1","2828.05","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1261.52","175","2414.38","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1800","1517.25","1800","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Lower GI Procedures","5312","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","90170.79","90170.79","90170.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","69862.46","67261.67","76656.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2570.08","2570.08","2570.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2534.03","1586.2","101169.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","103825.85","103825.85","103825.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","6907.6","6907.6","6907.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","713.62","601.97","1236.21","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1375.97","1375.97","35208.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Lower GI Procedures","5313","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","40073.32","40073.32","40073.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","275","275","275","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Complex GI Procedures","5331","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","137328.49","137328.49","137328.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","74505.44","72586.17","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10371.27","10371.27","10371.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","12770.66","12770.66","12770.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","96196.61","89505.41","100184.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","57607.04","57607.04","57607.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","2557.36","2557.36","2557.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1382.69","1359.66","2001.24","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","83272.05","83272.05","83272.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6954.93","5162.34","12739.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","5341","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","137802.47","137802.47","163190.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76713","76713","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10632.39","10632.39","10632.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","113843.97","105130.64","128733.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","132601.02","132601.02","132601.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","131084.33","131084.33","131084.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2113.5","1715.56","2628.87","25","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","109617.36","94962.14","114751.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10326.25","10326.25","15646.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1360","1360","1360","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","5342","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","220419.52","220419.52","220419.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","146457.57","107163.72","218736.55","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","73795.89","10098.18","76713","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","17865.04","17865.04","17865.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","22432.06","22432.06","22432.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","139317.11","113490.15","175661.15","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","161595.81","138357.06","167820.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","540","540","540","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","155848.39","155848.39","155848.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","16707.76","16707.76","16707.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","82613.17","82613.17","82613.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","291.47","291.47","291.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2466.91","1144.41","4512.18","193","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","193645.01","193645.01","193645.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","103482.57","66550.21","131260.02","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","14540.2","275","20688.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Laparoscopy and Related Services","5361","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","166841.65","166841.65","247454.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76474.92","10300.15","85000","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","23207.77","23207.77","23207.77","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","13616.94","13616.94","13616.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","166701.43","166701.43","166701.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","208295.73","208295.73","249852.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","106788.8","106788.8","108081.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2386.83","1004.72","4072.55","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","134831.61","134831.61","134900","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","22061.16","22061.16","22061.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Laparoscopy and Related Services","5362","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","340.7","340.7","340.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Urology and Related Services","5371","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","514.66","258.66","608.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","135000","135000","135000","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","13145.99","13145.99","13145.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Urology and Related Services","5372","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","87198.27","87198.27","87198.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","42889.54","1647.6","70679.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7140.8","7140.8","8984.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","10179.54","10179.54","10179.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","48794.17","5570.96","66407.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","62084.8","61976.07","107830.99","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","696.12","464.46","1362.12","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","58383.03","58383.03","58383.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7896.86","2999.08","54490.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Urology and Related Services","5373","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","103893.07","103893.07","103893.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","76713","11400","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","10439.17","10439.17","10439.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","108714.9","108714.9","108714.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","138844.96","138844.96","156967.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","150","150","150","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2634.37","1308.97","11728.85","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11918.34","275","15218.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Urology and Related Services","5374","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","137225.78","137225.78","137225.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","72857.91","6187","76844.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11446.7","10254.8","23056.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","7436.36","7436.36","26659.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","136601.17","136601.17","136601.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","115436.78","115436.78","161093.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","11971.32","11971.32","11971.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","100","100","100","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1572.98","1464.26","4722.97","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","98183.7","95005.43","99712.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","13077.05","7166.86","16880.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Urology and Related Services","5375","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8525.01","8525.01","8525.01","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2065.13","2065.13","2065.13","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1269.24","1060.78","4837.59","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2797.79","2797.79","2821.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Dialysis","5401","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3750.55","2323.92","4516.05","49","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2526.53","1849.03","3456.94","54","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2165.63","290","3884.37","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","3474.9","2364.34","4814.25","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","80.44","78.48","295.2","873","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","3382.35","1885.74","4090.06","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Gynecologic Procedures","5411","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","5404.7","5404.7","5404.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","3098.98","2124.6","76713","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","3317.83","3317.83","4808.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","5082.03","5082.03","5082.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","78.48","78.48","300.53","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","2889.03","2889.03","2889.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Gynecologic Procedures","5412","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9166.37","9166.37","9166.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Gynecologic Procedures","5413","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","97841.62","97841.62","97841.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","73313.71","25652.53","75558.66","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9546.91","9546.91","9546.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","95662.06","7307.45","102514.39","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1500","1500","1500","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1095.38","279.3","2147.53","51","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","76836.75","58335.85","97678.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","14688.57","14688.57","14688.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Gynecologic Procedures","5414","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","116993.17","116993.17","149674.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","75584.87","75584.87","75584.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","13231.47","13231.47","13231.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","101220.8","90878.08","182310.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","134738.19","134738.19","134738.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1455.27","1004.55","1722.15","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","105083.48","105083.48","105083.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","275","275","275","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 5 Gynecologic Procedures","5415","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","200830.85","200830.85","200830.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","802.48","802.48","802.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Gynecologic Procedures","5416","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","370.11","370.11","370.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","314.6","161","1583.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1055.17","1055.17","1984.38","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1318.95","1318.95","1320.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2451.8","1698.78","14219.95","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","6506.76","6506.76","6506.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","713.62","268.28","958.62","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1360.6","1360.6","6353.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1147.45","1147.45","1147.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Procedures","5431","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2633.63","2633.63","2633.63","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Procedures","5432","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2050.14","1311","4983.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","38.38","38.38","38.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","4752.31","4752.31","4752.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","5901.11","5901.11","5901.11","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","315.08","186.24","712.75","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1471.7","1471.7","6928.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","431.81","246.95","1013.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nerve Injections","5441","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","5171.03","5171.03","5171.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","5016.27","874","5293.71","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","551.49","424.09","636.14","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","532.11","532.11","2450.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1115.2","344.4","5386.77","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","6046.4","6046.4","7429.65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","2675","2611.95","3181.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","559.97","322.21","765.22","53","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","175","175","3357.48","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","533.61","175","1464.68","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nerve Injections","5442","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3910.87","3910.87","3910.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","907.58","87.4","1311","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","683.54","545.23","924.32","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1022.32","683.54","1024.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1672.8","1152.6","1878.16","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","542","542","542","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","1445.47","1445.47","2675","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","681.55","681.55","1581.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","577.12","223.1","789.4","57","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","715","175","5639.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","850.82","175","1953.48","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nerve Injections","5443","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2586","1692.35","3199.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1731.6","1385.28","1740.71","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1733.6","1733.6","1733.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","3255.77","3243.92","3497.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","2382.27","2382.27","2382.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","923.62","523.51","1028.87","37","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1919.7","175","2952.23","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1560.1","25","2080.1","26","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Intraocular Procedures","5491","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","3632","3632","3632","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","171.5","171.5","171.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Extraocular, Repair, and Plastic Eye Procedures","5503","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","5308.19","1381.38","14772.87","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","5466.68","935.77","8575.58","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","128.8","119.6","803.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","128.8","128.8","128.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6166.9","1698","11998.66","20","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","5624.55","5004.25","8662.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","485.48","194.6","854.41","137","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","6661.5","6661.5","6661.5","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1942.42","216.93","7092.14","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","893.27","275","903.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging without Contrast","5521","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","1844.37","521.25","3804.66","35","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1496.88","1196.74","4932.77","54","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1536.2","1536.2","1536.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","888.27","888.27","888.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1718.74","304.42","4808.81","40","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","2084.94","1667.95","7333.56","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","250","250","250","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","3893.81","3893.81","3893.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","216.72","216.72","487.28","600","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1360.62","280.23","3207.11","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","155.56","155.56","862.31","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","63.29","63.29","93.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging without Contrast","5522","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","16465.59","16465.59","16465.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1694.38","1694.38","9687.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","353.59","353.59","353.59","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","8063.28","8063.28","8063.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","956.91","956.91","956.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1011.04","160.44","2281.61","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1422.16","1422.16","1422.16","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Imaging without Contrast","5523","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","7013.85","7013.85","7013.85","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","5692.4","4321.86","9317.28","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","641.65","227.74","805.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","4020.67","3961.43","6269.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","9634.47","5426.76","10390.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","19013.05","12521.72","22884.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","269.32","269.32","269.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","709.68","239.76","1095.84","64","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","5000","206.47","6676.06","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","802.07","159.78","3762.17","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","187.9","187.9","187.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Imaging without Contrast","5524","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","748.65","673.78","873.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","655.91","607.6","668.64","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","208.33","208.33","265.72","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","260.41","195.3","285.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","736.24","122.61","767.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","931.32","931.32","1442.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","178.72","131.12","208.56","78","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","668.52","200","11353.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","260.41","25","260.91","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","122.61","122.61","192.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Imaging with Contrast","5571","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","24666.4","6456.89","29063.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","9144.15","5963.64","12540.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","523.41","523.41","839.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","8875.89","5122.7","8963.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","15053.28","15053.28","15053.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1046.65","8.95","1707.92","33","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","5287.19","1331","12803.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","522.41","275","1254.46","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Imaging with Contrast","5572","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","2491.17","2491.17","2491.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2277.06","1828.72","3020.03","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","470.24","470.24","590.2","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","590.8","590.8","590.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2834.21","2120.66","3321.74","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","3222.96","2428.33","3829.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","4593.42","4593.42","4593.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1229.08","564.4","1234.64","79","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","2298.99","1409.32","3296.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","577.01","25","1226.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","386.98","386.98","386.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Nuclear Medicine and Related Services","5591","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","2354.81","2354.81","2354.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1982.44","1982.44","6789.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","629.9","629.9","787.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","787.38","787.38","787.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","2321.88","2321.88","6267.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","728.68","728.68","1245.32","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","5277.57","5277.57","5277.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1148","1148","1148","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","1173","1173","1173","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Nuclear Medicine and Related Services","5592","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","57595.54","57595.54","62681.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","13989.65","12130.69","44081.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1527.73","1527.73","3751.5","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1909.67","1909.67","1909.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","15926.55","14270.11","61506.88","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","45901.4","45901.4","45901.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","41025.96","41025.96","41025.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","2446.8","543.12","4879.31","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","12367.82","12367.82","12367.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1909.67","647.02","6153.26","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","629.98","629.98","629.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Nuclear Medicine and Related Services","5593","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","428.4","428.4","6764.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","535.49","535.49","535.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","465.97","465.97","465.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","12152.66","12152.66","12152.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","11257","1088.55","11257","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","5325.28","5325.28","5325.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Therapeutic Radiation Treatment Preparation","5612","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","14585.48","14585.48","14585.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","2157.06","2157.06","2157.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","11257","7110","11257","42","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","5973.2","5412.04","7886.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","2325.04","2325.04","11693.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6321.22","3812.66","6529.04","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Therapeutic Radiation Treatment Preparation","5613","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","44808.69","44808.69","44808.69","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7413.17","7413.17","7413.17","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","11257","11037","11257","103","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","10537.96","9176.56","11056.28","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","12778.06","12778.06","12778.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","13268.29","9855.21","13499.34","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Radiation Therapy","5622","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","31947","31947","31947","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","16199.68","16199.68","16199.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","14544.04","7350.59","40029.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","29359.96","16542.2","43870.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","30783.07","2138","84921.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","86149.44","86149.44","86149.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","50","50","50","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","11257","11037","11257","623","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","16459.31","8098.79","47367.15","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","40707.87","40707.87","40707.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","8080.38","8080.38","8080.38","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Radiation Therapy","5623","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","11842.66","11842.66","11842.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","14799.68","14582.88","26676.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","15805.32","15805.32","15805.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 6 Radiation Therapy","5626","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","504.56","504.56","504.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapeutic Nuclear Medicine","5661","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","12.53","12.53","12.53","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Pathology","5671","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2227.12","1170.4","5334.95","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","250.66","250.66","250.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","2545.92","2545.92","2545.92","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","100.4","44.63","253.67","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","250.66","250.66","250.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","250.67","250.67","250.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Pathology","5672","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","4183.53","4183.53","8895.02","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","10562.36","10562.36","10562.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","189.22","107.44","662.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","703.83","703.83","703.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Pathology","5673","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","109.08","109.08","109.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","687.17","518.23","62416.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","423.24","215.99","600.68","55","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","590.1","488.9","751.68","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","673.35","673.35","673.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","461.16","150.91","17126.58","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","34674.8","26338.48","34674.8","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","406.8","134.16","840.51","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","8952.72","8952.72","8952.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Drug Administration","5691","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","16800.26","74.71","38565.89","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","7884.72","2474.19","14317.16","19","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","476.36","221.24","2868.18","93","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","257.99","234.26","400.25","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6710.57","648.6","6710.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","111.18","111.18","111.18","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","750.3","98.91","11175.42","284","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","469.83","246.18","34666.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","251.52","104.11","9169.31","117","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","50.19","50.19","50.19","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Drug Administration","5692","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","2357.04","1822.7","5835.91","106","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","2201.78","1008.42","17705.99","123","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","440.74","308.2","6794.43","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1857.58","375.69","4511.19","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1413.6","1076.83","15037.64","143","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1193.4","1084.98","6597.13","113","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","6210.61","365.36","6531.83","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","310.08","310.08","310.08","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","47161.56","47161.56","47161.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","266.03","205.2","7504.91","711","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1830.13","1053.45","35531.45","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","313.7","38.7","3578.52","71","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Drug Administration","5693","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","35628.11","10216.07","103287.23","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","21504.31","2578.46","88895.33","92","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2368.28","628.61","15991.47","82","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","23064.4","687.68","23750.01","16","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","37442.82","9966.09","113340.11","111","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","9543.91","3316.18","91069.93","23","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","5505.77","230.02","19092.7","581","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","10070.95","2532.84","36627.26","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3033.83","1078.89","14140.63","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Drug Administration","5694","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1947.49","1947.49","3529.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","4702.47","4702.47","4702.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","706.39","274.12","1628.65","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Diagnostic Tests and Related Services","5721","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","2018.94","2018.94","2018.94","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","4365.1","1606.37","4797.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","364.41","364.41","364.41","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1821.42","1411.07","52839.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","967.32","967.32","967.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","228.12","228.12","228.12","67","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1638.27","1638.27","2022.62","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","455.52","455.52","455.52","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Diagnostic Tests and Related Services","5722","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","138.49","8.6","564.57","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","4.97","4.97","204.91","41","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","3.91","3.91","3.91","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","14.39","12.44","65","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","7.72","7.72","229.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","18.6","18.6","18.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","307.15","307.15","307.15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","65","6.55","107.14","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","5.03","5.03","108.29","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 1 Minor Procedures","5731","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1092.32","125.55","1713.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","597.09","597.09","1669.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1347.57","1347.57","1347.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","430.56","430.56","430.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","660.74","474.88","1721.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","345","345","693.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","699.06","699.06","699.06","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 2 Minor Procedures","5732","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","247.4","124.38","1088.13","28","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","223.51","88.13","789.78","120","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","86.89","17.26","276.57","48","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","205.45","86.89","205.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","330.88","86.89","675.24","89","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","234.53","149.14","620.88","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","291.25","291.25","291.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","130.55","30","194.05","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","7.78","7.78","7.78","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","4285.14","4285.14","4285.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","94.08","37.82","161.05","463","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","7913.57","7913.57","7913.57","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","250.94","88.66","882.96","59","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","86.89","10","218.9","39","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","35","15","229.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 3 Minor Procedures","5733","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","229.46","183.57","1594.88","89","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.55","188.55","188.55","83","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","90.55","90.55","90.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","225.17","180.13","939.26","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1139.39","1139.39","2190.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","783.12","783.12","783.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","5.46","5.46","424.3","229","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","701.6","79.73","757.79","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.56","188.55","188.56","56","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Level 4 Minor Procedures","5734","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","7355.12","7355.12","7355.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","3508.09","1068.84","7395.65","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","5709.58","5709.58","5709.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","12046.7","12046.7","12046.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","3741.06","300","20000.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1401.68","712","17538","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","20137.12","20137.12","20137.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","12894.39","10154.39","14337.14","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","6078.27","1106.34","13445.86","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cardiac Rehabilitation","5771","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","5773.07","5544.9","7322.07","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","765.79","765.79","768.87","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","6081.82","5856.3","15379.45","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","17999.47","17999.47","17999.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1560.88","1067.85","1765.66","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","957.24","275","962.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Resuscitation and Cardioversion","5781","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","8182.84","8182.84","8182.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1917.58","437.47","4147.08","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","3826.7","3826.7","6690.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","5244.25","5244.25","5244.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","681.17","681.17","2017.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","304.4","207.19","553.24","53","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","3288.07","3288.07","4730.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","31614.76","31614.76","31614.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pulmonary Treatment","5791","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","96079.22","96079.22","96079.22","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Doxorubicin inj 10mg","7046","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","523.82","523.82","523.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","959.56","712.63","959.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","605","605","605","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","633.73","633.73","633.73","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Rabies vaccine, im","9139","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9387.36","9387.36","9387.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9397.71","9397.71","9397.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Fecal?microbiota jslm 1 ml","9142","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","436.7","86.34","474.45","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","483.35","483.35","483.35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","89.29","89.29","89.29","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","567.56","567.56","567.56","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","72.22","25","518.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, durolane 1 mg","9174","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","521.12","521.12","521.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj., perseris, 0.5 mg","9181","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","805.23","805.23","805.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","509.04","16.29","1053.76","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1899.71","1899.71","1899.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1086.49","1086.49","1086.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1125.76","109.69","1355.46","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","6.43","6.43","6.43","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","16.23","16.23","16.23","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Leuprolide acetate suspnsion","9217","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","283.81","283.81","283.81","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","100.68","100.68","100.68","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","173.83","74.75","1391.74","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","1793.54","1735.84","1793.54","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","18.75","18.75","18.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1562.25","1562.25","1562.25","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1642.84","10","1737.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, denosumab","9272","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1733.3","1733.3","1733.3","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj mvasi 10 mg","9329","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","170.42","170.42","170.42","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","111.84","88.67","249.33","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","239.74","239.74","239.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, cabote rilpivir 2mg 3mg","9414","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","925.2","925.2","925.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Injection, nivolumab","9453","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1490.72","1490.72","1490.72","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukocytes reduced","9512","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","2291.95","2291.95","2291.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"RBC leukoreduced irradiated","9522","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1590.82","1590.82","1932.98","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","630.12","629.5","815.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","1253.74","1253.74","1253.74","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","1790.58","1790.58","2801.49","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Platelets pheresis path redu","9536","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","104.19","40","244.95","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","168.8","30","198.8","84","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.51","188.51","189.98","161","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","188.51","135.44","188.51","15","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","30","2.98","152.83","38","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","180.96","30","276.9","21","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","261.4","261.4","261.4","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","64","15","189.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","188.51","188.51","188.51","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","128","57.6","128","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","136.4","136.4","138.71","1598","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","35","35","35","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","170.51","95.58","193.46","109","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","188.52","10","198.52","155","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","15","15","15","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-OPPS Clinic Services","N700","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","114.07","15","296.39","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","150.47","30","558.1","788","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","126.2","50.02","449.09","2838","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","182.21","108.94","241.77","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","26.87","7.12","188.51","1157","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","61.04","8.91","188.51","206","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","176.95","17.18","333.57","2252","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","121.68","19.3","368.53","775","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","92.93","36","218.4","32","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","153.6","16.09","373.01","128","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","9.09","9.09","280.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","100.51","8.02","350.43","17","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","200.48","200.48","200.48","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","76.5","72.25","520.37","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","65.91","8.5","192.28","3647","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","226.73","50","1865.58","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","153.35","40.83","292.99","1547","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","36","8.91","188.52","869","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","89.64","89.64","89.64","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Clinical Diagnostic Lab Services","N800","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","40","11.2","212.4","223","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","123.32","123.32","123.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","103.26","103.26","103.26","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","147.79","147.79","147.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","172.2","172.2","172.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","82.36","82.36","82.36","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Therapy Services","N801","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","100.48","92.82","147.84","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Pharmacy Services","N806","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","55031.32","55031.32","55031.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","657.7","657.7","657.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Observation, Other","N811","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","1144.89","122.39","1644.99","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","1309.31","100.31","1502.39","34","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","111.12","111.12","111.12","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","122.85","48.24","1685.29","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","1328.15","109.51","1418.4","22","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","206","206","206","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","7","7","1341.39","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","1460.9","43.03","1764.53","113","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","87.34","37.79","1626.17","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","74.93","74.93","74.93","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","688.04","7","1504.32","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Non-covered Services","N900","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","101.75","101.75","101.75","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Anesthesia, bundled","N901","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","465.63","188.81","847.1","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","244.11","100.95","750.64","292","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","183.96","72.14","664.03","1122","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","179.85","25.16","281.38","140","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","179.28","17.47","193.53","18","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","222.4","34.87","628.84","487","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","259.18","74.57","738.1","226","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","85","50","483.48","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","215.23","70.97","660.69","24","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","874.61","874.61","874.61","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","664.55","664.55","664.55","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","90.79","18","263.5","1379","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","311.96","125","657.96","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","222.23","77.52","729.28","377","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","117.17","10","261.83","176","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","117.17","15","313.72","50","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Packaged Services","N902","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","589.19","283.72","671.79","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","180.75","39.2","618.98","266","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","110.55","50.66","471.24","970","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","254.62","113.18","502.74","221","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","322.66","273.2","502.07","44","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","138.43","53.76","506.74","457","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","215.63","50.38","544.12","194","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","741.27","358.05","741.27","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","151.04","46.96","841.1","31","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","151.82","151.82","151.82","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","206.99","85","429.44","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","27.68","9","220.5","532","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","361.77","361.77","756.97","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","219.44","57.89","573.14","337","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","284.72","114.93","616.67","158","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","106.1","15","234.1","36","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Influenza Vaccines & Pneumococcal Pneumonia Vaccines","N903","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","874","699.2","1179.9","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","1152.6","1152.6","1152.6","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","517.2","517.2","517.2","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","580.94","56","708.9","11","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","3673.5","3673.5","4081.67","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","175","175","175","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Recognized by OPPS","N905","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Aetna","Hmo","","","[All OP services (%BC): 62] [OP Surgery  (%BC): 62] [Observation (%BC): 62] [Emergency Department (%BC): 62] [Occupational Therapy (%BC): 62] [Physical Therapy (%BC): 62] [Respiratory Services/Therapy  (%BC): 62] [Speech Therapy (%BC): 62] [All Other OP (%BC): 62]","583.7","583.7","583.7","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Aetna","Ppo","","","[All OP services (%BC): 69] [OP Surgery  (%BC): 69] [Observation (%BC): 69] [Emergency Department (%BC): 69] [Occupational Therapy (%BC): 69] [Physical Therapy (%BC): 69] [Respiratory Services/Therapy  (%BC): 69] [Speech Therapy (%BC): 69] [All Other OP (%BC): 69]","431.24","287.57","759.12","124","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","All Commercial Plans","","","[OP Surgery  (%BC): 56 Maximum Reimbursement 76713] [Observation (%BC): 56] [Emergency Department (%BC): 56] [Occupational Therapy (%BC): 56] [Physical Therapy (%BC): 56] [Respiratory Services/Therapy  (%BC): 56] [Speech Therapy (%BC): 56] [All Other OP (%BC): 56]","338.62","227.08","617.48","366","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Anthem Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","225.31","99.6","354.17","30","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Blue Cross","Narrow Netwok Other Commercial Plan","","","[OP Surgery  (%BC): 34 Maximum Reimbursement 85000] [Observation (%BC): 34] [Emergency Department (%BC): 34] [Occupational Therapy (%BC): 34] [Physical Therapy (%BC): 34] [Respiratory Services/Therapy  (%BC): 34] [Speech Therapy (%BC): 34] [All Other OP (%BC): 34]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","243.28","243.28","324.47","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Blue Shield","Hmo/Ppo","","","[All OP services (%BC): 63] [OP Surgery  (%BC): 63] [Observation (%BC): 63] [Emergency Department (%BC): 63] [Occupational Therapy (%BC): 63] [Physical Therapy (%BC): 63] [Respiratory Services/Therapy  (%BC): 63] [Speech Therapy (%BC): 63] [All Other OP (%BC): 63]","433.75","250.21","883.73","150","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Cigna","Hmo/Ppo","","","[All OP services (%BC): 78] [OP Surgery  (%BC): 78] [Observation (%BC): 78] [Emergency Department (%BC): 78] [Occupational Therapy (%BC): 78] [Physical Therapy (%BC): 78] [Respiratory Services/Therapy  (%BC): 78] [Speech Therapy (%BC): 78] [All Other OP (%BC): 78]","399.94","268.8","715.96","98","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","First Health/Coventry","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","243.71","243.71","243.71","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Healthnet","All Commercial Plans","","","[OP Surgery  (%BC): 68 Maximum Reimbursement 2500 Charge Threshold 2500 (%BC): 35] [Cardiac Cath (%BC): 70] [Lap Chole (%BC): 70] [Lithotripsy (%BC): 70 Maximum Reimbursement 5000] [Emergency Department (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675] [All Other OP (%BC): 68 Charge Threshold 2675 (%BC): 35 Maximum Reimbursement 2675]","469.7","316.68","559.08","14","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Healthnet","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Healthsmart/Interplan","All Commercial Plans","","","[All OP services (%BC): 70] [OP Surgery  (%BC): 70] [Observation (%BC): 70] [Emergency Department (%BC): 70] [Occupational Therapy (%BC): 70] [Physical Therapy (%BC): 70] [Respiratory Services/Therapy  (%BC): 70] [Speech Therapy (%BC): 70] [All Other OP (%BC): 70]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Humana","Medicare Managed Care Plan","","","[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Kaiser","All Commercial Plans","","","[All OP services (%BC): 45] [OP Surgery  (%BC): 45] [Observation (%BC): 45] [Emergency Department (%BC): 45] [Occupational Therapy (%BC): 45] [Physical Therapy (%BC): 45] [Respiratory Services/Therapy  (%BC): 45] [Speech Therapy (%BC): 45] [All Other OP (%BC): 45]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Kaiser","Radiation Therapy All Commercial Plans","","","[Lesser Than Charges paid at %: 100] [Radiation Therapy ($): 11257]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Multiplan","All Commercial Plans","","","[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Partnership","Medicaid Managed Care Plan","","","[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhcs.ca.gov/provgovpart/]","217.21","9","355.53","394","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Phcs","All Commercial Plans","","","[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","958.24","958.24","958.24","1 through 10","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Sutter Health Plus","All Commercial Plans","","","[OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Radiation Therapy  (%BC): 50] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","","","","0","other","","","No services performed during 15-month lookback period."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","All Commercial Plans","","","[OP Surgery  (%BC): 62.50 Maximum Reimbursement 135000] [Stereotactic Radiosurgery (%BC): 62.50 Maximum Reimbursement 50000] [Stereotactic Radiosurgery-Fractionated (%BC): 62.50 Maximum Reimbursement 50000] [Observation (%BC): 62.50 Maximum Reimbursement 55000] [Emergency Department (%BC): 62.50 Maximum Reimbursement 21150] [Cardiac Rehabilitation Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Cardiology (%BC): 62.50 Maximum Reimbursement 5000] [Echocardiology (%BC): 62.50 Maximum Reimbursement 5000] [EKG/ECG  (%BC): 62.50 Maximum Reimbursement 5000] [Holter Monitor/Telemetry (%BC): 62.50 Maximum Reimbursement 5000] [Peripheral Vascular Lab (%BC): 62.50 Maximum Reimbursement 5000] [EEG (%BC): 62.50 Maximum Reimbursement 5000] [MEG (%BC): 62.50 Maximum Reimbursement 5000] [Sleep Studies (%BC): 62.50 Maximum Reimbursement 5000] [Chemotherapy (%BC): 62.50 Maximum Reimbursement 50000] [Nuclear Medicine (%BC): 62.50 Maximum Reimbursement 5000] [Oncology (%BC): 62.50 Maximum Reimbursement 50000] [Radiation Therapy  (%BC): 62.50 Maximum Reimbursement 55000] [CT OP Scan (%BC): 62.50 Maximum Reimbursement 5000] [MRI OP (%BC): 62.50 Maximum Reimbursement 5000] [Imaging Services (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Diagnostic (%BC): 62.50 Maximum Reimbursement 5000] [Mammography-Screening (%BC): 62.50 Maximum Reimbursement 5000] [Positron Emission Tomography (%BC): 62.50 Maximum Reimbursement 5000] [Radiology (%BC): 62.50 Maximum Reimbursement 3000] [Ultrasound Imaging (%BC): 62.50 Maximum Reimbursement 5000] [Laboratory (%BC): 62.50 Maximum Reimbursement 3000] [Pathology (%BC): 62.50 Maximum Reimbursement 3000] [Hemodialysis (%BC): 62.50 Maximum Reimbursement 50000] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 62.50 Maximum Reimbursement 50000] [Occupational Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Physical Therapy (%BC): 62.50 Maximum Reimbursement 5000] [Respiratory Services/Therapy  (%BC): 62.50 Maximum Reimbursement 1500] [Speech Therapy (%BC): 62.50 Maximum Reimbursement 5000] [OP High Cost Drugs ($): 0 Charge Threshold 65500 (%BC): 28] [Hyperbarics (%BC): 62.50 Maximum Reimbursement 5000] [IV Therapy (%BC): 62.50 Maximum Reimbursement 50000] [Pulmonary Function (%BC): 62.50 Maximum Reimbursement 5000] [Pulmonary Rehabilitation (%BC): 62.50 Maximum Reimbursement 5000]","423.53","270.22","745.14","129","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Unitedhealthcare","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","235.63","145.12","643.96","13","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Wha","All Commercial Plans","","","[OP Surgery  (%BC): 35] [Observation (%BC): 35] [Emergency Department (%BC): 35] [Occupational Therapy (%BC): 35] [Physical Therapy (%BC): 35] [Respiratory Services/Therapy  (%BC): 35] [Speech Therapy (%BC): 35] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 65] [All Other OP (%BC): 35 Maximum Reimbursement 1800]","360.91","250.21","1075.52","12","other","","","Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Not Billable to FI","N907","APC","","","","","","","facility","outpatient","","","","","","Wha","Medicare Managed Care Plan","","","[APC ($): FEE SCHEDULE]","","","","0","other","","","No services performed during 15-month lookback period."
"Cath Pt Therm Icy Fem Short","11078539","CDM","278","RC","","","","","facility","both","","","","4372.88","4372.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Airway Exchange","11078541","CDM","271","RC","","","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Pt Therm Cool Line Ij","11078545","CDM","278","RC","","","","","facility","both","","","","2598.75","2598.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Pt Therm Quattro Fem Long","11078547","CDM","278","RC","","","","","facility","both","","","","4964.38","4964.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Samplng 1/2 Node","11078549","CDM","983","RC","31652","HCPCS","","","facility","both","","","","3609.82","3609.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Outpateint Treatment Rm Charge","11085107","CDM","761","RC","","","","","facility","both","","","","1374","1374","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Procedure Care Per Hour","11085115","CDM","710","RC","","","","","facility","both","","","","1676","1676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Referral Observation Ca","11085123","CDM","762","RC","G0379","HCPCS","","","facility","both","","","","624","624","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","11085131","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","11085149","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","11085165","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","11085173","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","11085181","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardioversion Elective Externa","11094141","CDM","480","RC","92960","HCPCS","","","facility","both","","","","5366","5366","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Wash","11100102","CDM","983","RC","31622","HCPCS","","","facility","both","","","","750.44","750.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Art Cath - Mntr/Trnsfs Spx Prq","11100104","CDM","983","RC","36620","HCPCS","","","facility","both","","","","125.63","125.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cpr","11100105","CDM","983","RC","92950","HCPCS","","","facility","both","","","","982.36","982.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","11100106","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","11100108","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","11100109","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hsp Ip/Obs Dc Day Mgmt 30Mn/<","11100111","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","11100112","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","11100113","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","11100114","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","11100115","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","11100116","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","11100117","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","11100118","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Swan Ganz Bedside","11100120","CDM","983","RC","93503","HCPCS","","","facility","both","","","","250.08","250.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Chest Tube","11100121","CDM","983","RC","32551","HCPCS","","","facility","both","","","","442.83","442.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Aortic Circulation Assist","11100122","CDM","983","RC","33971","HCPCS","","","facility","both","","","","1986.84","1986.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Trach Tube Chg Pre Fistula","11100123","CDM","983","RC","31502","HCPCS","","","facility","both","","","","100.58","100.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","11100124","CDM","983","RC","62270","HCPCS","","","facility","both","","","","436.93","436.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Tracheostomy Planned","11100125","CDM","983","RC","31600","HCPCS","","","facility","both","","","","872.51","872.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ins Picc Age 5 Yrs/>","11100126","CDM","983","RC","36569","HCPCS","","","facility","both","","","","273.6","273.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abdominal Paracentesis","11100127","CDM","983","RC","49082","HCPCS","","","facility","both","","","","655.77","655.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/O Imaging","11100128","CDM","983","RC","32554","HCPCS","","","facility","both","","","","704.03","704.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","11100129","CDM","983","RC","32555","HCPCS","","","facility","both","","","","995.5","995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Brush","11100130","CDM","983","RC","31623","HCPCS","","","facility","both","","","","843.96","843.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Biopsy(S)","11100131","CDM","983","RC","31625","HCPCS","","","facility","both","","","","1085.77","1085.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Lavage","11100132","CDM","983","RC","31624","HCPCS","","","facility","both","","","","783.55","783.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Needle Bx Ea","11100133","CDM","983","RC","31629","HCPCS","","","facility","both","","","","1434.84","1434.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oxygen Update % 02","11100134","CDM","983","RC","94681","HCPCS","","","facility","both","","","","172.22","172.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Intubation Et Emergent","11100135","CDM","983","RC","31500","HCPCS","","","facility","both","","","","400.91","400.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ins Non-Tunnel Cv Cath 5 Yr","11100136","CDM","983","RC","36556","HCPCS","","","facility","both","","","","673.41","673.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","11100137","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","11100138","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guide Vascular Access","11100139","CDM","983","RC","76937","HCPCS","","","facility","both","","","","115.28","115.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheobronch Via Old Incision","11100141","CDM","983","RC","31615","HCPCS","","","facility","both","","","","526.21","526.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Lung Bx Each","11100142","CDM","983","RC","31628","HCPCS","","","facility","both","","","","1148.37","1148.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Ivntj Perph Les","11100143","CDM","983","RC","31654","HCPCS","","","facility","both","","","","378.47","378.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","11100144","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Skull For Implantation","11100145","CDM","983","RC","61107","HCPCS","","","facility","both","","","","848.57","848.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroguide For Vein Device","11100146","CDM","983","RC","77001","HCPCS","","","facility","both","","","26","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Bronch Ebus Sampling 3/> Node","11100147","CDM","983","RC","31653","HCPCS","","","facility","both","","","","3756.98","3756.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Clear Airways","11100148","CDM","983","RC","31645","HCPCS","","","facility","both","","","","819.19","819.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Level Iii","11100149","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Fb Removal","11100150","CDM","983","RC","31635","HCPCS","","","facility","both","","","","870.25","870.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","11100151","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","11100152","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Right Heart Cath","11100153","CDM","983","RC","93451","HCPCS","","","facility","both","","","","2771.22","2771.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","11100154","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Lung Bx Addl","11100155","CDM","983","RC","31632","HCPCS","","","facility","both","","","","189.45","189.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","11100156","CDM","983","RC","99152","HCPCS","","","facility","both","","","","164.03","164.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea","11100157","CDM","983","RC","99153","HCPCS","","","facility","both","","","","35.04","35.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Reclear Airway","11100158","CDM","983","RC","31646","HCPCS","","","facility","both","","","","412.26","412.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","11100159","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Repair Wnd 2.5Cm/<","11100160","CDM","983","RC","12001","HCPCS","","","facility","both","","","","279.59","279.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","11100161","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Paracentesis W/Imaging","11100162","CDM","983","RC","49083","HCPCS","","","facility","both","","","","967.17","967.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","11100163","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","11100164","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","11100165","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","11100166","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vad Different Session","11100167","CDM","983","RC","33992","HCPCS","","","facility","both","","","","552.47","552.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated/Mult","11100168","CDM","983","RC","10061","HCPCS","","","facility","both","","","","638.6","638.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","11100169","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","11100171","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/ Image","11100173","CDM","983","RC","32557","HCPCS","","","facility","both","","","","2010.25","2010.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg 41-60 Minutes (Read Only)","11100174","CDM","983","RC","95812","HCPCS","","","facility","both","","","26","1080.44","1080.44","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Cardioversion Electric Ext","11100175","CDM","983","RC","92960","HCPCS","","","facility","both","","","","487.63","487.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Drainage Pleura W/O Image","11100179","CDM","983","RC","32556","HCPCS","","","facility","both","","","","2201.16","2201.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Init Hosp Care I","11100180","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","11100181","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","11100182","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","11100184","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","11100185","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","11100186","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","11100187","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care 30 Min","11100188","CDM","983","RC","99497","HCPCS","","","facility","both","","","95","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care Plan +30M","11100189","CDM","983","RC","99498","HCPCS","","","facility","both","","","95","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Mod Sedat Endo Service >5Yrs","11100190","CDM","983","RC","G0500","HCPCS","","","facility","both","","","","187.39","187.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath","11100191","CDM","983","RC","51702","HCPCS","","","facility","both","","","","192.97","192.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Inpt/Ed Teleconsult 50M","11100192","CDM","983","RC","G0426","HCPCS","","","facility","both","","","95","383.76","383.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt/Ed Teleconsult 30M","11100194","CDM","983","RC","G0425","HCPCS","","","facility","both","","","95","281.76","281.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Ins Tunneled Cv Cath Age 5/>","11100195","CDM","983","RC","36558","HCPCS","","","facility","both","","","","2636.37","2636.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","11100196","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peripheral Bld Smear By Phys","11100198","CDM","983","RC","85060","HCPCS","","","facility","both","","","","67.26","67.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tunneled Cvad W Port Age 5","11100199","CDM","983","RC","36561","HCPCS","","","facility","both","","","","3102.03","3102.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Iv Push","11100201","CDM","983","RC","96374","HCPCS","","","facility","both","","","","127.29","127.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lyse Chest Fibrin Subq Day","11100202","CDM","983","RC","32562","HCPCS","","","facility","both","","","","248.33","248.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv Hosp Same Date Ii 50 Min","11100203","CDM","983","RC","99235","HCPCS","","","facility","both","","","","485.92","485.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","11100204","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","11100205","CDM","983","RC","99406","HCPCS","","","facility","both","","","","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","11100206","CDM","983","RC","99407","HCPCS","","","facility","both","","","","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","11100207","CDM","983","RC","99497","HCPCS","","","facility","both","","","","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Outpatient Treatment Rm Charge","18000117","CDM","761","RC","","","","","facility","both","","","","582","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag/Iv Inf Init","18000118","CDM","761","RC","96365","HCPCS","","","facility","both","","","","1009","1009","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Add On","18000119","CDM","761","RC","96366","HCPCS","","","facility","both","","","","208","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Declot Vascular Device","18000120","CDM","761","RC","36593","HCPCS","","","facility","both","","","","1191","1191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrap Knee","18000123","CDM","271","RC","","","","","facility","both","","","","86.25","86.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Procedure Care Per Hour","18000125","CDM","710","RC","","","","","facility","both","","","","1216","1216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Referral Observation Ca","18000133","CDM","762","RC","G0379","HCPCS","","","facility","both","","","","661","661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","18000158","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","18000166","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","18000174","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","18000208","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4124","4124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Outpatient Clinic Visi","18000216","CDM","761","RC","99211","HCPCS","","","facility","both","","","","137","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bili Lights","18000224","CDM","270","RC","","","","","facility","both","","","","471.19","471.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","18000264","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","18000272","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bili Lights","18010010","CDM","270","RC","","","","","facility","both","","","","471.19","471.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrap Knee","18010011","CDM","271","RC","","","","","facility","both","","","","86.25","86.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","18010012","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Procedure Care Per Hour","18010013","CDM","710","RC","","","","","facility","both","","","","1216","1216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag/Iv Inf Init","18010014","CDM","761","RC","96365","HCPCS","","","facility","both","","","","1009","1009","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Add On","18010015","CDM","761","RC","96366","HCPCS","","","facility","both","","","","208","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","18010016","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4124","4124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Outpatient Clinic Visi","18010018","CDM","761","RC","99211","HCPCS","","","facility","both","","","","137","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Declot Vascular Device","18010019","CDM","761","RC","36593","HCPCS","","","facility","both","","","","1191","1191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","18010020","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","18010021","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Referral Observation Ca","18010022","CDM","762","RC","G0379","HCPCS","","","facility","both","","","","661","661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","18010023","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","18010024","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Outpatient Treatment Rm Charge","18010026","CDM","761","RC","","","","","facility","both","","","","582","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Outpatient Treatment Rm Charge","18400101","CDM","761","RC","","","","","facility","both","","","","1512","1512","","","","","","","","","","","","","Gross Charge Type: Standard"
"Declot Vascular Device","18400102","CDM","761","RC","36593","HCPCS","","","facility","both","","","","1191","1191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Add On","18400103","CDM","761","RC","96366","HCPCS","","","facility","both","","","","208","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Init","18400104","CDM","761","RC","96365","HCPCS","","","facility","both","","","","1009","1009","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Procedure Care Per Hour","18400119","CDM","710","RC","","","","","facility","both","","","","1265","1265","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Referral Observation Ca","18400127","CDM","762","RC","G0379","HCPCS","","","facility","both","","","","661","661","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","18400135","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Iv 1 Hr","18400136","CDM","331","RC","96413","HCPCS","","","facility","both","","","","1466","1466","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","18400143","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","18400151","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","18400185","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4124","4124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Outpatient Clinic Visi","18400193","CDM","761","RC","99211","HCPCS","","","facility","both","","","","137","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bili Lights","18400201","CDM","270","RC","","","","","facility","both","","","","786.19","786.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","18400241","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","18400259","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forced Inpatient Profee Split","18400270","CDM","983","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","20000000","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation  Addl Hr","20000001","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","20000002","CDM","391","RC","36430","HCPCS","","","facility","both","","","","5716","5716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","20000003","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","20000004","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","20100000","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation  Addl Hr","20100001","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","20100002","CDM","391","RC","36430","HCPCS","","","facility","both","","","","5716","5716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","20100003","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","20100004","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","20200000","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation  Addl Hr","20200001","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","627","627","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","20200002","CDM","391","RC","36430","HCPCS","","","facility","both","","","","5716","5716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","20200003","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","20200004","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","20300000","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","20300001","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","734","734","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","20300002","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","20300003","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine","20300004","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","21000020","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Room Flat Rate","21000021","CDM","761","RC","","","","","facility","both","","","","159","159","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Bed","21000022","CDM","270","RC","","","","","facility","both","","","","500","500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hri F/Up-Rpt Dev And Physical","21000138","CDM","510","RC","","","","","facility","both","","","","298","298","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Ii","21000139","CDM","510","RC","99212","HCPCS","","","facility","both","","","","228","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Iii","21000140","CDM","510","RC","99213","HCPCS","","","facility","both","","","","256","256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Iv","21000141","CDM","510","RC","99214","HCPCS","","","facility","both","","","","270","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level V","21000142","CDM","510","RC","99215","HCPCS","","","facility","both","","","","275","275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Level Ii","21000154","CDM","510","RC","99202","HCPCS","","","facility","both","","","","228","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Level Iii","21000155","CDM","510","RC","99203","HCPCS","","","facility","both","","","","256","256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Lvel Iv","21000156","CDM","510","RC","99204","HCPCS","","","facility","both","","","","245","245","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Level V","21000157","CDM","510","RC","99205","HCPCS","","","facility","both","","","","275","275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference - Medical","21000161","CDM","510","RC","","","","","facility","both","","","","164","164","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference - Medical","21000179","CDM","510","RC","","","","","facility","both","","","","429","429","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference","21000187","CDM","510","RC","","","","","facility","both","","","","53","53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference","21000195","CDM","510","RC","","","","","facility","both","","","","60","60","","","","","","","","","","","","","Gross Charge Type: Standard"
"Social Evaluation","21000203","CDM","510","RC","","","","","facility","both","","","","126","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speech Sound Lang Comprehen","21000211","CDM","440","RC","92523","HCPCS","","","facility","both","","","","361","361","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp 1St Hr","21000230","CDM","918","RC","96112","HCPCS","","","facility","both","","","","482","482","","","","","","","","","","","","","Gross Charge Type: Standard"
"Devel Tst Phys/Qhp Ea Addl","21000232","CDM","918","RC","96113","HCPCS","","","facility","both","","","","242","242","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nurse Assess/Instr/Educ Ea 30M","21000237","CDM","510","RC","","","","","facility","both","","","","103","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Seat Challenge 60 Mins","21000242","CDM","419","RC","94780","HCPCS","","","facility","both","","","","332","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clinic Coordinator","21000245","CDM","510","RC","","","","","facility","both","","","","131","131","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference Nurse Per 15 M","21000253","CDM","510","RC","","","","","facility","both","","","","18","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Case Conference Social Wk Per","21000261","CDM","510","RC","","","","","facility","both","","","","19","19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Telephone Consult-Nurse Per 15","21000279","CDM","510","RC","","","","","facility","both","","","","26","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Telephone Consult-Sw Per 15 Mi","21000287","CDM","510","RC","","","","","facility","both","","","","26","26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Developmental Screen (Early De","21000288","CDM","510","RC","96110","HCPCS","","","facility","both","","","","174","174","","","","","","","","","","","","","Gross Charge Type: Standard"
"Center Coordinator","21000289","CDM","510","RC","Z4300","HCPCS","","","facility","both","","","","138","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","21000295","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4124","4124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Outpatient Clinic Visi","21000303","CDM","761","RC","99211","HCPCS","","","facility","both","","","","137","137","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun  Admin","21000329","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","21000337","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Seat Challenge","21000339","CDM","761","RC","","","","","facility","both","","","","479","479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Car Seat Challenge Ea Addl 30","21000340","CDM","761","RC","94781","HCPCS","","","facility","both","","","","167","167","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision","21000341","CDM","761","RC","","","","","facility","both","","","","58","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cchd","21000343","CDM","460","RC","","","","","facility","both","","","","202","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Introsyte 1.9Fr26Ga","21000345","CDM","272","RC","","","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Premicath 1Fr Neonat Catheter","21000353","CDM","272","RC","","","","","facility","both","","","","467.25","467.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Light Bili-Light","21000500","CDM","270","RC","","","","","facility","both","","","","797.1","797.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc<5","21000674","CDM","761","RC","36568","HCPCS","","","facility","both","","","","5129","5129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vygon Epicut Cava Cath 30Cm","21009915","CDM","272","RC","","","","","facility","both","","","","636.56","636.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evoked Response Audiometry","21025812","CDM","471","RC","92650","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Humn Milk Fortifr","21070115","CDM","250","RC","","","","","facility","both","","","","44","44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oxy Monitor Sys","21090014","CDM","270","RC","","","","","facility","both","","","","12341.44","12341.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Set","21090022","CDM","272","RC","","","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Feed Tube 5Fr","21090055","CDM","272","RC","","","","","facility","both","","","","1026.25","1026.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Feed Tube 8Fr","21090063","CDM","272","RC","","","","","facility","both","","","","859.69","859.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leukocyte Removal Filter Pxla","21091434","CDM","272","RC","","","","","facility","both","","","","720.56","720.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","28000026","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","28000106","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bili Lights","28000107","CDM","270","RC","","","","","facility","both","","","","480.05","480.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","28000114","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evoked Response Audiometry","30010102","CDM","471","RC","92650","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cchd","30010104","CDM","460","RC","","","","","facility","both","","","","202","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision","30010106","CDM","761","RC","","","","","facility","both","","","","58","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","30010110","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4124","4124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Newborn Outpatient Clinic Visi","30010128","CDM","761","RC","99211","HCPCS","","","facility","both","","","","151","151","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bili Lights","30010136","CDM","270","RC","","","","","facility","both","","","","483.99","483.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun  Admin","30010160","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","30010178","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Single/Comb","39000052","CDM","771","RC","90471","HCPCS","","","facility","both","","","","192","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Cot-Stress Test","39001003","CDM","720","RC","59020","HCPCS","","","facility","both","","","","2820","2820","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 30Min Cl1","39001037","CDM","710","RC","","","","","facility","both","","","","7506","7506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl2","39001045","CDM","710","RC","","","","","facility","both","","","","17258","17258","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl3","39001052","CDM","710","RC","","","","","facility","both","","","","25179","25179","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl4","39001060","CDM","710","RC","","","","","facility","both","","","","35972","35972","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Ea Addl Minute","39001078","CDM","710","RC","","","","","facility","both","","","","250","250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Transfusion Admin","39001080","CDM","391","RC","36430","HCPCS","","","facility","both","","","","667","667","","","","","","","","","","","","","Gross Charge Type: Standard"
"Version Cephalic External","39001086","CDM","720","RC","59412","HCPCS","","","facility","both","","","","12553","12553","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation And Curettage","39001128","CDM","360","RC","","","","","facility","both","","","","16569","16569","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exam Under Anesthesia","39001136","CDM","360","RC","","","","","facility","both","","","","13807","13807","","","","","","","","","","","","","Gross Charge Type: Standard"
"Influenza Virus Immun Admin","39001142","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","166","166","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vaccine No","39001150","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Ea Addl S/C","39001153","CDM","771","RC","90472","HCPCS","","","facility","both","","","","191","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Sc/Im Ther/Proph/Diag","39001154","CDM","771","RC","96372","HCPCS","","","facility","both","","","","192","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hepatitis B Virus Immun Admin","39001155","CDM","771","RC","G0010","HCPCS","","","facility","both","","","","192","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vacuum Extractor Kiwi","39001168","CDM","271","RC","A4649","HCPCS","","","facility","both","","","","140.85","140.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Check Hourly Charge","39002001","CDM","720","RC","S4005","HCPCS","","","facility","both","","","","714","714","","","","","","","","","","","","","Gross Charge Type: Standard"
"Test Non Stress Fetal","39003009","CDM","720","RC","59025","HCPCS","","","facility","both","","","","3368","3368","","","","","","","","","","","","","Gross Charge Type: Standard"
"Labor Charge-First Hour","39010004","CDM","720","RC","","","","","facility","both","","","","680","680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Labor Charge-Each Add Hour","39010012","CDM","720","RC","","","","","facility","both","","","","335","335","","","","","","","","","","","","","Gross Charge Type: Standard"
"Delivery Charge","39010111","CDM","720","RC","","","","","facility","both","","","","4614","4614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pp Spec Procedure","39010707","CDM","360","RC","","","","","facility","both","","","","1170","1170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inf Vac Extr","39020003","CDM","272","RC","","","","","facility","both","","","","1131.55","1131.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vacuum Extractor Mity Vac","39020029","CDM","272","RC","","","","","facility","both","","","","534.19","534.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrd Es D5Mm Shft L12Cm","40000007","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","208","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L50Mm Dia4Mm Cort Ti","40000008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","72","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L56Mm Dia4Mm Cort Ti","40000009","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","72","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Sm W11Xl124Mm","40000010","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","636.3","636.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L19Mm Thk1.9Mm Ant","40000011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2608.85","2608.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L142Mm 6 H Nonsterile","40000012","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1454.25","1454.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L137Mm Xln 6 H","40000013","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.45","1647.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L370Mm 18 H St R Cndyl","40000014","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2689","2689","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Grft Del For Bne Void Fill","40000015","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia12Mm 15Mm Extn","40000016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338.1","338.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia8Mm Univ Dk","40000017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.1","1451.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mandibular 2 Mm Dia","40000018","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.1","175.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L14Mm Dia2Mm Cort Ti","40000019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.37","174.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drp Surg W112Xl137In Hip Sms","40000020","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","187","187","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Foam W25Xl25.2Cm","40000021","CDM","272","RC","A6210","HCPCS","","","facility","both","","","","21","21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Foam W6Xl6.75In Shal","40000022","CDM","623","RC","A6210","HCPCS","","","facility","both","","","","16","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cem Bne 40Gm W/ Gent Hi Visc","40000024","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7266.85","7266.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 16Mm Ss T10 Ft","40000026","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 22Mm Ss T15 Ft","40000027","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 30Mm Loprfl Scr","40000028","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","125","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 42Mm Ss T15 St","40000029","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","495.6","495.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm Blde L10Mm","40000030","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1496.25","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Srg Phasix Sepra 6X4In","40000032","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4768.05","4768.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Surgalloy V-Loc 180 3-0","40000033","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","259.35","259.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Radl 7.5Mm Evol Std Elb","40000034","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4582.2","4582.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Radl 22Mm Evol +2Mm Elb","40000035","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3856.65","3856.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.5Mm Sonicanchor","40000036","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1103","1103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchr Sut No 2-0 V-5 Drlbt","40000037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","915.6","915.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gw Escp 0.018 In 260 Cm Navipr","40000038","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","241.68","241.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle, Aspir System Covidien","40000052","CDM","272","RC","","","","","facility","both","","","","732.9","732.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle, Biopsy Sharkcore Fine","40000053","CDM","272","RC","","","","","facility","both","","","","732.9","732.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 105Mm Ti Fem","40000054","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.66","965.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 100Mm Ti Fem","40000055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1124","1124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 300Mm 10Mm Tfn-Adv Tpr","40000056","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","876.29","876.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Cryabl 10Cm Cryoice Mlbl","40000057","CDM","270","RC","C2618","HCPCS","","","facility","both","","","","3341.83","3341.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shft Scrdrvr L55Mm Dia2.4Mm","40000060","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","511.35","511.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hd Rmr Dia8.5Mm Mdllry Fr Cut","40000061","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","408.45","408.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hd Rmr Dia10Mm Mdllry Fr Cut","40000062","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","408.45","408.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hd Rmr Dia11Mm Mdllry Fr Cut","40000063","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","408.45","408.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hd Rmr Dia11.5Mm Mdllry Fr Cut","40000064","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","408.45","408.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L382Mm Dia11Mm","40000065","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","952.94","952.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L499Mm Dia11Mm","40000066","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","981","981","","","","","","","","","","","","","Gross Charge Type: Standard"
"Twister Surg Wre For","40000067","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","395.85","395.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manip Endoscp For","40000068","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","126","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia2.7Mm Cort","40000069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.76","207.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L10Mm Dia3.5Mm Cort","40000070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","206","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L20Mm Dia3.5Mm Sm Sys","40000080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L48Mm Dia3.5Mm Sm Sys","40000082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne Sm L44Mm Dia4Mm Dk Blu","40000083","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L58Mm Dia4Mm Cort Fll","40000088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.4Mm Guide Wire/ 150Mm Length","40000096","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","175.1","175.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.7Mm Cannulated Drill Bit Qc","40000097","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","900.42","900.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Ticron Sz 2-0 L75Cm","40000100","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","175","175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern Xl W5Xl7In R","40000101","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","473.7","473.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Polysrb 4-0 Cv-23 30In Ud","40000103","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","154","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Inj Amntc Viaflow 2Cc","40000104","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","5933.87","5933.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft  Bn Accell Evo3","40000110","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3260.25","3260.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Accell Evo3C Dbm Canc","40000111","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2107.35","2107.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +8.5Mm Offset","40000112","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1081.2","1081.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L142Mm 6 H Nonsterile","40000113","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1454.25","1454.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L157Mm 8 H Nonsterile","40000114","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1672.65","1672.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L110Mm 7 H St R Sup","40000115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1218","1218","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L75Mm Sht 3 H","40000116","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.45","1647.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne M L88Mm 4 H Nonsterile","40000117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1746.3","1746.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne M L88Mm 4 H Nonsterile","40000118","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.45","1647.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L153Mm Xln 9 H","40000119","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.1","1598.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L147Mm Xln 7 H","40000120","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1693.99","1693.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 7 Std L Cr Cocr","40000121","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5008.42","5008.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Fem 3-5 Tib Cd H12Mm","40000122","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2494","2494","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Fem 3-11 Tib Ef","40000123","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.64","2643.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L47Mm 5Deg M 6 H L Mt","40000124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3494.4","3494.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L142Mm 6 H St L Med","40000125","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2056","2056","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L237Mm 14 H Nonsterile","40000126","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2771","2771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Accell Evo3 Canc Dbm","40000129","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1147","1147","","","","","","","","","","","","","Gross Charge Type: Standard"
"8Mm Dia X 5Cm, 75Cm Catheter","40000130","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4379.55","4379.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appl Clp L33Cm Shft Dia11Mm 8","40000133","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","4121.25","4121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bg Spec Retrv M C240Ml Mouth","40000134","CDM","270","RC","","","","","facility","both","","","","852.56","852.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sep Thromctmy Sz 4 L200Cm For","40000135","CDM","270","RC","C1757","HCPCS","","","facility","both","","","","1386","1386","","","","","","","","","","","","","Gross Charge Type: Standard"
"True Sz Thrmdil Disp Swn Gz","40000136","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cem Persona","40000137","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2921.36","2921.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dlys 62Cm Coil 2 Cuf","40000138","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","1285.44","1285.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Trnspar W1.5Xl1.75In Iv","40000139","CDM","272","RC","A4221","HCPCS","","","facility","both","","","","2.1","2.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Troponin Reagent","40000140","CDM","270","RC","","","","","facility","both","","","","767.55","767.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Troponin Calibrator","40000141","CDM","270","RC","","","","","facility","both","","","","370.65","370.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Microbiol Tst 5W Bbl","40000142","CDM","270","RC","","","","","facility","both","","","","118","118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing Vis-U-All High Temp 9 X","40000143","CDM","270","RC","","","","","facility","both","","","","188","188","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tbng Strl 12Inx100Ft Hi Temp","40000144","CDM","270","RC","","","","","facility","both","","","","276.15","276.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Extn 2.4Ml L21In Str Std","40000145","CDM","270","RC","S1015","HCPCS","","","facility","both","","","","2.1","2.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm 130Deg","40000146","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817","2817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg L115Mm Dia10.5Mm","40000147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","888","888","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L170Mm Dia6.5Mm Thrd","40000148","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.55","452.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L170Mm Dia6.5Mm Thrd","40000149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.55","452.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L180Mm Dia6.5Mm Thrd","40000150","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.55","452.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L86Mm 6 H Bilat","40000152","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079","1079","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L99Mm 7 H Bilat","40000153","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1100","1100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L112Mm 8 H Bilat","40000154","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1117","1117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L375Mm Dia8Mm Univ Dk","40000155","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.1","1451.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L138Mm 10 H Bilat","40000156","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1153","1153","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L212Mm Thk3.4Mm 16 H","40000157","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","883.05","883.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L241Mm Thk3.4Mm 18 H","40000158","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","943","943","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L267Mm Thk3.4Mm 20 H","40000159","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1048","1048","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Drl For 2.4Mm Plt","40000161","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","688.8","688.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Drl 10Mm Acl Pcl Knee Rg","40000162","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","785.4","785.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Drl 9Mm Acl Pcl Knee Rg","40000163","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","785.4","785.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Sut Knee Lp Scorpion","40000164","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","470.4","470.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32.5Mm Od4.5Mm Ti","40000165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L23Mm Dia7Mm 30%","40000166","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","567","567","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L28Mm Dia7Mm 30%","40000167","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","567","567","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut Mic Str For Rc And","40000168","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","338.1","338.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut 70Deg Sht Mic Nit","40000169","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","338.1","338.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L46Mm Dia4Mm Ss St","40000170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L50Mm Dia4Mm Ss Cann","40000171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Lp Lng Thrd","40000172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L150Mm Dia0.053In","40000173","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","59.16","59.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.6Mm Cann For Ank","40000174","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","389.55","389.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Autogrft Trnsf 10Mm Sm","40000175","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","896.7","896.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Ablat Xl 90Deg Aspir","40000176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appl Surg Xl L38Cm For Arista","40000177","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","382.57","382.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snr Surg L230Cm Dia2.8Mm Loop","40000178","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","223.38","223.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cem Bne 40Gm W/ Gent Hi Visc","40000179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 3 L102Mm Nk L30Mm","40000180","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2828.13","2828.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drp Surg W44Xl60In Fab Reinf","40000181","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","178","178","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L180Cm","40000182","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","682.5","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Polyhesive Ii Return","40000183","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","11.01","11.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Protct For 8Mm Cf Rod M","40000184","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","11.3","11.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frcp Surg L4.75In 1X2 Teeth","40000185","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","19.8","19.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frcp Surg L7.5In Art Ss Satin","40000186","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","53.77","53.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Fiberwire Sz 0 L38In","40000187","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","55","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trcr Endoscp 12Mm L100Mm","40000188","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","65.05","65.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Template Bend L87Mm 7 H","40000189","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","71.17","71.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Compr L150Mm Dia1.6Mm","40000190","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","89.28","89.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L110Mm Dia1.5Mm Qc","40000191","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","123.53","123.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Infl 60Ml 15Atm Disp","40000193","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","142.97","142.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L125Mm Dia2.7Mm Qc","40000194","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","146.33","146.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Torq .014-.018In Blu Vasc","40000195","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","162.54","162.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Guid For Aug Rm Comphsve","40000196","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","178.1","178.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Shrt Hndl 4Mm Hnck Aor","40000198","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch 2.5Mm Shrt Hndl Strl","40000199","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","169.6","169.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speculum Vag M W1 5/16Xl4In Ss","40000200","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","173.4","173.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L360Mm Dia8Mm C","40000202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","226","226","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.7Mm W/ Stp","40000203","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","302.4","302.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L340Mm Dia4.2Mm 3 Flut","40000204","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","369.62","369.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 405Cc P4.4Cm","40000205","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 750Cc P6.7Cm","40000206","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Mamm 470Cc Dia12.25Cm","40000207","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst Impl 495Cc P6.1Cm","40000208","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 525Cc P6.2Cm","40000209","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 545Cc P6.2Cm","40000210","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Orth L55Mm Hld For L","40000211","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","472.29","472.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Orth L105Mm Hld For L","40000212","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","491.97","491.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Surg L5.5Mm Ft Ank Cann","40000213","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","495.6","495.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drp Surg Spec Proc 4 Pc","40000214","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","566.26","566.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Drlbt Dia2Mm Drl Guid Hndl","40000215","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","604.8","604.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Rumi 5.1Mm X 6.0Cmmm Lav","40000216","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","651.82","651.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Iu L6Cm Dia6.7Mm Wht Sil","40000217","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","651.82","651.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Iu L8Cm Dia6.7Mm Blu Sil","40000218","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","651.82","651.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Iu L10Cm Dia6.7Mm Grn Sil","40000219","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","651.82","651.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Uter L12Cm Dia6.7Mm Orng","40000220","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","651.82","651.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Iu L3.75Cm Dia5.1Mm Yel","40000221","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","652.87","652.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia3.2Mm Cann For Jone","40000222","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","707.87","707.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia1.7Mm Cann For","40000223","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","667.8","667.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Od2Mm Cann For Hdlss","40000224","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","667.8","667.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L10Mm Dia2.5Mm Sm","40000225","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Surg Dia3Mm Flut Mtch","40000226","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","748.57","748.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shears Endoscp L45Cm Dia5Mm","40000227","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","908.8","908.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Crv Dil 40Cm 18Fr Ck","40000228","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix M 6 Pos Multipin","40000229","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","969.04","969.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Surg Ad L174Mm Reduc","40000230","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","805.01","805.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manipulator Uter Cup 2.5Cm","40000231","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","924.18","924.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manipulator Uter 3Cm Ultem","40000232","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","945.74","945.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manipulator Uter 3.5Cm Ultem","40000233","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","965.77","965.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Manipulator Uter 4Cm Ultem","40000234","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","924.18","924.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cup Manip Dia2.5Cm Pneumo Occl","40000235","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","955.25","955.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Es Cup Dia3Cm Pneumo","40000236","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","955.25","955.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Es Cup Dia3.5Cm Pneumo","40000237","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","955.25","955.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Es Cup Dia4Cm Pneumo","40000238","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","955.25","955.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Endoscp L240Cm Shth","40000239","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1272","1272","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg Sgl Pk Disp","40000240","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1669.5","1669.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L45Mm Dia5.5Mm Ti","40000241","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3116.93","3116.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drape Surg Adpt For Advincula","40000242","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3714.05","3714.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drape Adpt Uter Pos Sys","40000243","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3936.89","3936.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Marlex Bard 2X12In","40000261","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","155","155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blake Drain 10Fr","40000262","CDM","272","RC","","","","","facility","both","","","","169.79","169.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Bard 3Dmax Left Medium","40000263","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","353.43","353.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Symbotex Collage","40000264","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","836.96","836.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Physiomesh (Ophy 1520)","40000265","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1419.7","1419.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Bard 3Dmax Left Large","40000266","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","360.5","360.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Srg Ethicon Physiomesh 10","40000268","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","662.05","662.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surgical Symbotex Polyest","40000269","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","915.44","915.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Vasc 16 X 10 Cm Xenosure","40000270","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","1103.44","1103.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 4.3Mm 34Mm Ti T25","40000271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","284.55","284.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 4.3Mm 42Mm Ti T25","40000272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.25","320.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 100Mm Ti Fem","40000273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","295.05","295.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 300Mm 10Mm Tfn-Adv Tpr","40000274","CDM","272","RC","","","","","facility","both","","","","855.75","855.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Cath Midline 4Fr","40000278","CDM","272","RC","","","","","facility","both","","","","279.3","279.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Purewick Fem Ext Urine Cath","40000279","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","20","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Bcmps 28Mm 9Mm","40000280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","523.11","523.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Tx Tghtrp Acl Rt Ti","40000281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 105Mm Ti Fem","40000282","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","912","912","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 500Mm 6-9Mm Tfn-Adv","40000284","CDM","272","RC","","","","","facility","both","","","","925","925","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Srg 2.5X950Mm Rod/Ball","40000285","CDM","272","RC","","","","","facility","both","","","","181","181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Fmrl Cmpnt Sz12 Rt Std","40000286","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.55","4862.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 10 Std 4 Knee Ccr","40000287","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.55","4862.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 4 Std  R Cr Cocr","40000288","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.55","4862.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 11 Std R Cr Cocr","40000289","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.55","4862.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Fem 6-9 Tib Ef H12Mm","40000290","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2494","2494","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Bone Cellurar","40000292","CDM","278","RC","","","","","facility","both","","","","4096.57","4096.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibialis Posterior","40000293","CDM","278","RC","","","","","facility","both","","","","2750","2750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allograft Achilles 10Mm","40000294","CDM","278","RC","","","","","facility","both","","","","3668.44","3668.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Femoral Implant (2000-Up)","40000295","CDM","278","RC","","","","","facility","both","","","","3111.29","3111.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cartiledge Implant (2000-Up)","40000296","CDM","278","RC","","","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Axoguard Nerve Protector","40000298","CDM","278","RC","","","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor/Screw Bn/Bn Tis/Bn (200","40000299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4081.88","4081.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Impl (500-20","40000300","CDM","278","RC","","","","","facility","both","","","","907.5","907.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft, Bone Imp (500-2000)","40000301","CDM","278","RC","","","","","facility","both","","","","912.8","912.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast Impl (500-2000)","40000302","CDM","278","RC","","","","","facility","both","","","","2126.25","2126.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intraocular Impl (500-2000)","40000303","CDM","278","RC","","","","","facility","both","","","","826.88","826.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intraocular Lens (500-2000)","40000304","CDM","278","RC","","","","","facility","both","","","","782.25","782.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit, Lead Linear","40000305","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","2700","2700","","","","","","","","","","","","","Gross Charge Type: Standard"
"System, Charging Percision","40000306","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","2700","2700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibia Impl (500-2000)","40000308","CDM","278","RC","","","","","facility","both","","","","2153.25","2153.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular (75-500)","40000309","CDM","278","RC","","","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast Impl (75-500)","40000311","CDM","278","RC","","","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intraocular Lens (75-500)","40000312","CDM","278","RC","","","","","facility","both","","","","362.25","362.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor/Screw Bn/Bn Bn/Tis (16-","40000316","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.25","185.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Amniotic 2X3 Impl","40000319","CDM","278","RC","","","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drsg Slv Grnfm 26In","40000320","CDM","272","RC","","","","","facility","both","","","","153","153","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Us Piv Accucath Ace 20G","40000322","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","120","120","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sug Progrip 15 X 10 Cm Sl","40000323","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","840.54","840.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia9Mm R Fem","40000326","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm 125Deg","40000327","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blde Im L95Mm Dia10.35Mm Prox","40000328","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","910.2","910.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Nar 42Mm Ti 2.4Mm Scr 6","40000329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1152.6","1152.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Std 77Mm Ti 2.4Mm Scr 7","40000330","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1354.18","1354.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5Mm Ti Lcp Hook Plate 3 Hol","40000331","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","932.27","932.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Hook 3H 3.5Mm Strl","40000332","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","951.6","951.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L28Mm Dia2.7Mm","40000334","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn T8 Strdrv 2.7X30Mm","40000335","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn T8 Strdrv 2.7X32Mm","40000336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bne L80Mm Ti Ally For Fe","40000337","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","637.56","637.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne M L64Mm St L Calcnl T","40000338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1703.99","1703.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl 2.65Mm Gd Hndl Cnt","40000340","CDM","272","RC","","","","","facility","both","","","","604.8","604.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Ascp Fx Grvty Synchfix","40000343","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2090","2090","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Ortholoc","40000344","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill 3 Mm","40000345","CDM","272","RC","","","","","facility","both","","","","665.28","665.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl 20X5.5Mm Bme Elt 1.5","40000346","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2520","2520","","","","","","","","","","","","","Gross Charge Type: Standard"
"Template Sz Ast Strl","40000347","CDM","272","RC","","","","","facility","both","","","","176","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stpl Bne Fix W18Xl18Mm Leg","40000348","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1814.4","1814.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stpl Bne Fix W20Xl15Mm Wre","40000349","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2160","2160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl 2Mm Speedtraid Gd Hndl","40000350","CDM","272","RC","","","","","facility","both","","","","604.8","604.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"16Cm X 12Cm Parietex Progrip","40000351","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","918.86","918.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Bcmps 23Mm 8Mm","40000359","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","493.5","493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx Tghtrp Fibertag Acl","40000360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","958","958","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fx 14Mm Tghtrp Rnd Acl","40000361","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","642.6","642.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Hum Tiss Artc Cart Nat","40000362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6247.5","6247.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Screw 5.00 - 15.99","40000367","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48","48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000369","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Screw 500.01 - 2000.00","40000370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3213","3213","","","","","","","","","","","","","Gross Charge Type: Standard"
"Supply Disposable 15.01 - 775","40000376","CDM","270","RC","","","","","facility","both","","","","195.01","195.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Escp Inst 220Cm 10.5-12Mm","40000377","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Supply Disposable 500.01 - 20","40000378","CDM","270","RC","","","","","facility","both","","","","3244.5","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Supply Disposable 2000.01+","40000379","CDM","270","RC","","","","","facility","both","","","","5250","5250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Extr For 4.5Mm Bne Scr","40000393","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","187.42","187.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Extr For 6.5Mm Canc 7Mm","40000394","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","187.42","187.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 7.5Fr L180Cm Blln","40000395","CDM","272","RC","A7520","HCPCS","","","facility","both","","","","714","714","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Bio Tiss W4Xl10In Bov","40000396","CDM","278","RC","Q4104","HCPCS","","","facility","both","","","","17202.94","17202.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hndl Chsl/Goug Ao Rm Cplr Cnct","40000397","CDM","270","RC","","","","","facility","both","","","","891.28","891.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kt Compliance W/ Endoglde","40000398","CDM","272","RC","A4550","HCPCS","","","facility","both","","","","228.22","228.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld Pace 5.7Fr L52Cm Vent Sil","40000399","CDM","278","RC","C1898","HCPCS","","","facility","both","","","","839.13","839.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lnr Wst W45Xl49In Thk1.5Mil","40000400","CDM","270","RC","","","","","facility","both","","","","153.78","153.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prng Cpap Inf Sept W2Mm Nare","40000401","CDM","270","RC","A4615","HCPCS","","","facility","both","","","","187.5","187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmr Surg Hllw Complt For 4.5Mm","40000402","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","746.36","746.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Extr Dia2.5Mm Conic","40000403","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","572.96","572.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Extr For Fem Ti And Tib","40000404","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","372.73","372.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shft Scrdrvr T15 Stardrv","40000405","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","544.99","544.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snr Endoscp Shth Dia2.4Mm Ovl","40000406","CDM","270","RC","","","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L13Mm Dia4Mm Orsiro","40000407","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Gi 5Fr L4Cm Pancreas W","40000408","CDM","278","RC","C1877","HCPCS","","","facility","both","","","","177.5","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tb Rmr Spare For 309.45 Hllw","40000409","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","466.28","466.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort 23Mm Repl Resilient","40000410","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort 29Mm Repl Resilient","40000411","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort Sz 27Mm Bov Pericard","40000412","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia3.5Mm Cort","40000413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L54Mm Dia4.5Mm Cort","40000414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.66","49.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L56Mm Dia4.5Mm Cort","40000415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L58Mm Dia4.5Mm Cort","40000416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia4.5Mm Cort","40000417","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L62Mm Dia2.7Mm","40000418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L64Mm Dia2.7Mm","40000419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L66Mm Dia2.7Mm","40000420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L68Mm Dia2.7Mm","40000421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia2.7Mm","40000422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia2.7Mm","40000423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","105.82","105.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia2.7Mm","40000424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L150Mm Dia0.9Mm Blnt","40000425","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L228Mm Dia2Mm Ss","40000426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","119.25","119.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L10Mm Dia2Mm Ti St","40000427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.1","120.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L8Mm Dia2Mm Ti St For","40000428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.3","113.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L6Mm Dia2Mm Cort Ti St","40000429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","117.83","117.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia2.7Mm Cort","40000430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","117.13","117.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L15Mm Dia4.75Mm Hd","40000431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","183.59","183.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L5Mm Dia2Mm Cort Ti St","40000432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","169.54","169.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L22Mm Dia2.4Mm Ti St","40000433","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia2.4Mm Ti St","40000434","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia2.4Mm Ti St","40000435","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia2.4Mm Ti St","40000436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Bttrs L18Mm Dia1.8Mm Dst","40000437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L150Mm Dia1.6Mm Thrd","40000438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.08","222.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia2.7Mm Ti St","40000439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.67","237.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia3.2Mm Cntrl Scr","40000440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","264.68","264.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L9In Dia3.2Mm","40000441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","283.01","283.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L240Mm Dia2.5Mm Calib","40000443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","327.47","327.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L52Mm Dia4Mm Ss Cann","40000444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia2.4Mm Cort","40000445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia2.4Mm Cort","40000446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L8Mm Dia2.4Mm Ti","40000448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia4Mm Grn Ti","40000449","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L70Mm Dia5Mm 3.5Mm","40000450","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L55Mm Dia5Mm 3.5Mm","40000451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia5Mm 3.5Mm","40000452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia5Mm 3.5Mm","40000453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Thk1.25Mm 2X2 H","40000454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","663.71","663.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne Sm L14Mm Dia2.5Mm Mag","40000455","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W13.5Xl116Mm","40000456","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","685.78","685.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne Sm L50Mm Dia3.5Mm Sys","40000458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 3.5Mm Dx Swivelock","40000462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","978","978","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut L13.5Mm Dia3.5Mm","40000463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","978","978","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L105Mm 5 H St L Dst","40000464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1244.71","1244.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Int W11Xh10Mm Wre","40000465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1248","1248","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W25.5Xl55Mm Wide 7X3","40000466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1252.21","1252.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L90Mm 2 H St L","40000468","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.16","1516.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L164Mm 12 H Bilat","40000469","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1589.6","1589.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L56Mm Lng St R","40000470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1732.31","1732.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 6 H Str For Sm Bne","40000471","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1671.08","1671.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W11Xl262Mm Thk4.2Mm","40000472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1677.01","1677.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L216Mm 16 H Bilat","40000473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1677.01","1677.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W11Xl298Mm Thk4.2Mm","40000474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1708.82","1708.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L242Mm 18 H Bilat","40000475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1708.82","1708.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L153Mm Xln 9 H St R","40000476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1709.61","1709.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L108Mm Lng 4 H St R","40000477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1772.6","1772.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W11Xl334Mm Thk4.2Mm","40000478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1786.02","1786.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Impl Menis Root Rep","40000479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1801.8","1801.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia7Mm Thrd","40000480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2154.45","2154.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L80Mm Dia7Mm Thrd","40000481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2154.45","2154.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L75Mm Dia7Mm Thrd","40000482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2154.45","2154.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L82Mm 4 H St R","40000483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2160.6","2160.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L112Mm 6 H L Antlat","40000484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2197.65","2197.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Hum Std For Comphsve Rev","40000485","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2419.97","2419.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L147Mm 8 H St R Prox","40000486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2416.05","2416.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L89Mm R Lat Fib","40000487","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3192","3192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Mt L18Mm Dia9.5Mm Toe Ti","40000488","CDM","278","RC","L8641","HCPCS","","","facility","both","","","","888.3","888.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Mt Dia 15Mm 2.5 X 3Mm","40000489","CDM","278","RC","L8641","HCPCS","","","facility","both","","","","3234","3234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snr Endoscp Shth Dia2.4Mm Ovl","40000525","CDM","272","RC","","","","","facility","both","","","","311.64","311.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Gi 5Fr L4Cm Pancreas W","40000526","CDM","278","RC","C1877","HCPCS","","","facility","both","","","","177.5","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Sw Unv W Stryk","40000527","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","529.2","529.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Srg Ant Pg Tlr Inbone Ii","40000528","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Tensix Dbm 5Ml Algrf","40000529","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2612.5","2612.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Xtrnfx 130Mm 6.5Mm","40000530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2726.25","2726.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 5Mm","40000531","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","873.6","873.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor Cmprh Thn Glnd Srg","40000532","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","919.42","919.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shft Scrdrvr Dia4Mm Cann Hex","40000533","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","591.93","591.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L300Mm Dia2.5Mm","40000535","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","121.69","121.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L90Mm Dia10.35Mm G Ti","40000537","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","970.31","970.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sl Im Resrb For 5Mm Angular","40000538","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","260.44","260.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pmp Pain Mgmt Sys 400Ml 2 Sel","40000539","CDM","270","RC","A4306","HCPCS","","","facility","both","","","","3047.63","3047.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surg 20Cm W/ Pos Sys Echo","40000540","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2782.5","2782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Impl Rivacor 7 Dr-T Df4","40000542","CDM","275","RC","C1721","HCPCS","","","facility","both","","","","20351.75","20351.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monitor Cardiac Implantable Mr","40000543","CDM","278","RC","C1764","HCPCS","","","facility","both","","","","5512.5","5512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld Icd Plexa Promri S Dx 65/15","40000544","CDM","278","RC","C1777","HCPCS","","","facility","both","","","","4029.95","4029.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pk Surg Proc Cath Lab St Ltx","40000545","CDM","272","RC","A4550","HCPCS","","","facility","both","","","","267.5","267.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld Pace 5.7Fr L45Cm Vent Sil","40000546","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","839.13","839.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Spnl L37Mm Lev 2 Ant Cerv","40000547","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2671.88","2671.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemkr Card 12.75Cc","40000548","CDM","275","RC","C1785","HCPCS","","","facility","both","","","","6902.13","6902.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Nonabsorbable Polyeth","40000549","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1110","1110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Bio Tiss W4Xl5In Bov","40000550","CDM","278","RC","Q4104","HCPCS","","","facility","both","","","","5968.8","5968.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L30Mm","40000551","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Io +18.5 Diopt L13Mm","40000552","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","334.21","334.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W15Xl15Cm Polypr","40000553","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","499.85","499.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000554","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1655.33","1655.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agnt Hemstat 1Gm Absrb Pwd","40000555","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","852.76","852.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld Pace 5.7Fr L52Cm Vent Sil","40000556","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","839.13","839.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 7.5Fr L180Cm Blln","40000557","CDM","272","RC","A7520","HCPCS","","","facility","both","","","","749.7","749.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Extr For 6.5Mm Canc 7Mm","40000558","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","187.42","187.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmr Surg Hllw Complt For 4.5Mm","40000559","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","746.36","746.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tb Rmr Spare For 309.45 Hllw","40000560","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","466.28","466.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Extr For 4.5Mm Bne Scr","40000561","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","187.42","187.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shft Scrdrvr T15 Stardrv","40000562","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","544.99","544.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Extr For Fem Ti And Tib","40000563","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","372.73","372.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Extr Dia2.5Mm Conic","40000564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","572.96","572.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia3Mm Cann For Hdlss","40000565","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","667.8","667.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cann Arthscp L4Cm Id8Mm Dbl","40000566","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","98.05","98.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia5Mm Str Cann Disp","40000567","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia5Mm Straight Cann","40000568","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","45","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clp Int L235Cm Wrk Chn","40000569","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","465.53","465.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clp Int L235Cm Wrk Chn","40000570","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","158.13","158.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Pessary Sz 2 2.25In Sil","40000571","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","158.13","158.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Io +20.0 Diopt L13Mm","40000572","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","365.71","365.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort 23Mm Repl Resilient","40000573","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort Sz 27Mm Bov Pericard","40000574","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","15303.75","15303.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort 29Mm Repl Resilient","40000575","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L9Mm Dia4Mm Orsiro","40000576","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aor Inspiris Resilia 19","40000577","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14437.5","14437.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort 21Mm Repl Resilient","40000578","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","15303.75","15303.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indigo Cath 6 + L Lumn Aspir","40000579","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","2818.75","2818.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sep Thromctmy L175Cm","40000580","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","1701","1701","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thromctmy L140Cm Rx L","40000581","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","3055.5","3055.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Aort Sz 25Mm Bov Pericard","40000582","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","15130.5","15130.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L13Mm Dia4Mm Orsiro","40000583","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Vcl 3-0 Ct2 18In Brd 8","40000584","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2449.91","2449.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 180Cm .035In","40000585","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Bio Tiss W4Xl10In Bov","40000586","CDM","636","RC","Q4104","HCPCS","","","facility","both","","","","17202.94","17202.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kt Compliance W/ Endoglde","40000587","CDM","272","RC","A4550","HCPCS","","","facility","both","","","","241.91","241.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prng Cpap Inf Sept W2Mm Nare","40000588","CDM","272","RC","A4615","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Balloon Dilatation","40000589","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2100","2100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Balloon Dilatation In","40000590","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2325","2325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L230Mm Dia2Mm","40000591","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","65.03","65.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L113Mm 11 H Ant","40000592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1247.88","1247.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"0.8Mm Guide Wire/ 100Mm Length","40000594","CDM","270","RC","","","","","facility","both","","","","132.3","132.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.1Mm Guide Wire/ 150Mm Length","40000595","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","150.53","150.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.6Mm Cann Drill Bit Qc/ 95Mm","40000596","CDM","270","RC","","","","","facility","both","","","","800.56","800.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cann Countersink For 2.0Mm Can","40000597","CDM","270","RC","","","","","facility","both","","","","875.14","875.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia5Mm Tib Lt","40000598","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L46Mm Dia5Mm Lat Fem","40000599","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L55Mm Dia12.5Mm St Ti","40000600","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","790.63","790.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L65Mm Dia12.5Mm St Ti","40000601","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","790.63","790.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia10Mm L Fem","40000602","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L345Mm Dia10Mm Grn Tib","40000603","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1451.59","1451.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L390Mm Dia10Mm Univ Lt","40000604","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1451.59","1451.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L375Mm Dia11Mm Univ Lt","40000605","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1451.59","1451.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm 125Deg","40000606","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000607","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","637.56","637.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000608","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","429.87","429.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L236Mm 9 H R Dst Fem","40000609","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","2117.56","2117.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.0Mm X 13Mm Orsiro Sirolimus","40000610","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.50Mm X 13Mm, 5Fr X 140Cm Len","40000611","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.50Mm X 30Mm, 5Fr X 140Cm Le","40000612","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Strg Ascp 5.5Mm Ntchbls","40000615","CDM","278","RC","C1771","HCPCS","","","facility","both","","","","1411.58","1411.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.25 X 15Mm Pantera Pro Semi-C","40000616","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5Mm X 30Mm Orsiro Sirolimus","40000617","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brush Endoscp 2 End Chn","40000618","CDM","270","RC","","","","","facility","both","","","","182.58","182.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tb Spec 3Ml Red Clsr M4Rt For","40000619","CDM","270","RC","","","","","facility","both","","","","408.11","408.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L80Mm Dia8Mm Shth","40000620","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3740.63","3740.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.0Mm X 22Mm Orsiro Sirolimus","40000621","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.0Mm X 35Mm Orsiro Sirolimus","40000622","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reservoir 3-Spike 120Ml Stand","40000623","CDM","270","RC","","","","","facility","both","","","","2632.5","2632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reservoir 3-Spike 120Ml Stand","40000624","CDM","270","RC","","","","","facility","both","","","","798.52","798.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Balloon Dilatation Pa","40000625","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tablet Aromatherapy Essential","40000626","CDM","270","RC","","","","","facility","both","","","","232","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phasix St Mesh With Open Posit","40000631","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","28310.63","28310.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Suture Anterior Cruciat","40000632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","826.88","826.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Suturing Curved With 2","40000633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1049.4","1049.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Sq 4X4In Abs Pd","40000634","CDM","272","RC","A6209","HCPCS","","","facility","both","","","","11.36","11.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Emb L80Cm Dia5.5Fr","40000635","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","195.2","195.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kt Ipg Senza","40000636","CDM","278","RC","C1822","HCPCS","","","facility","both","","","","33000","33000","","","","","","","","","","","","","Gross Charge Type: Standard"
"""5"""" X 7"""" (12.4Cm X 17.3Cm) Ext""","40000637","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","397.32","397.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infinity Tib Size 2","40000638","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","10748.06","10748.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Talar Sz 2 Ank Dome","40000639","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11403","11403","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Shldr 36Mm Std Hum Bear","40000640","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2725.9","2725.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 4 Nar R Knee Cocr","40000641","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2981.25","2981.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 33Cm 6.7Mm 18Fr","40000642","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","803.25","803.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Softpulse 7.5"""" Single-Loop""","40000643","CDM","270","RC","","","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"18 Mm X 4 Cm Balloon, 100Cm Sh","40000644","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","986.61","986.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"5 Fr X 120Cm Supreme Ep Cathet","40000645","CDM","270","RC","","","","","facility","both","","","","186","186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio L100Cm Dia5Fr","40000646","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","354.38","354.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth Od1.4Mm G Maxtorque","40000647","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","55.65","55.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"15Cm X 20Cm Phasix St Mesh Re","40000648","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","7553.24","7553.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.0Mm X 26Mm Orsiro Sirolimus","40000650","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"4Mm X 40Mm Balloon, 130Cm Cath","40000651","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2027.82","2027.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca Blln L4Cm Infl","40000652","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L11.5Cm Dia18Mm","40000653","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L13.5Cm Dst Dia16Mm","40000654","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L18Cm Aort","40000655","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","14555.63","14555.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Endopros L2.5Cm Dia7Mm","40000656","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4739.44","4739.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L59Mm Dia8-16Mm","40000657","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4599","4599","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Il Branch Comp","40000658","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","14503.13","14503.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L11.5Cm Dia20Mm","40000659","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc Intergard Wvn 36 Mm","40000660","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","965.48","965.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Infus 5Fr L50Cm","40000661","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","325.5","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Infus 5Fr L40Cm","40000662","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","325.5","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L135Cm Blln","40000663","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","627.9","627.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H21Mm Dia38Mm","40000664","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2256","2256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum Univ Std L122Mm","40000665","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4521.57","4521.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Davinci Robotic Pack","40000666","CDM","270","RC","","","","","facility","both","","","","886.95","886.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"9Mm X 60Mm 75Cm Delivery Epi","40000667","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","837.9","837.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"9Mm X 60Mm, 75Cm Delivery, Epi","40000668","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1535.63","1535.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Ef Fem 6-9","40000669","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Adpt 90Deg Starburst","40000670","CDM","270","RC","","","","","facility","both","","","","1622.25","1622.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-9 Tib","40000671","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Ef","40000672","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 6 Std L Knee","40000673","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 10 Nar R Knee","40000674","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Cd Fem 6-9","40000675","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-9 Tib","40000676","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 7 Std R Knee","40000677","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3263.4","3263.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 6 Nar R Knee","40000678","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nerve Axoguard Porci","40000679","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2776.5","2776.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 10Mm Mini Shldr Cocr","40000682","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4528.78","4528.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphere Glen Dia36Mm Reg Std","40000683","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2088.45","2088.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L35Mm Dia6.5Mm Hex","40000684","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 495Cc P6.1Cm","40000685","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1724.63","1724.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 525Cc P6.2Cm","40000686","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1724.63","1724.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 545Cc P6.2Cm","40000687","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1724.63","1724.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fix L10Mm Dia1Mm Cerclage","40000689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","114.08","114.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L6Mm Dia2Mm Cort Ss","40000691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.6","188.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L142Mm 6 H","40000692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1891.63","1891.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X7 H Ss Y Lok","40000693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","758.46","758.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L44Mm 5 H Bilat Ss","40000694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","728.55","728.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Platye Bne L53Mm 3X7 H Ss T Lo","40000695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","758.46","758.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surg Hllw Complt","40000696","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","746.36","746.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Orth Spare Cntr For Hllw","40000697","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","187.42","187.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extractor Surg Conic","40000698","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","144.15","144.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pull G Tb 20Fr Dome Bx 2","40000699","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","637.44","637.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Us St Rotational","40000700","CDM","270","RC","","","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing Suct L24In Dia 7Mm Pvc","40000702","CDM","290","RC","A7002","HCPCS","","","facility","both","","","","79.8","79.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leads","40000703","CDM","270","RC","","","","","facility","both","","","","405.3","405.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pk Prcdr Tx-Bn","40000704","CDM","270","RC","","","","","facility","both","","","","5099.06","5099.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Colon With 1.1Ox Lubricant","40000705","CDM","270","RC","","","","","facility","both","","","","341.04","341.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing Irrig Compatible W/Oly","40000706","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","338.68","338.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sponge Bottle Bbrush","40000707","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","175.5","175.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40000709","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","132.15","132.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lig M/L 3-10Mm Ves Tiss","40000710","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","132.15","132.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.00Mm X 35Mm, 5Fr X 140Cm Le","40000711","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tib Sz 3 Thk17Mm","40000712","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1645.88","1645.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Base Glen Sm Comphsve Mod","40000713","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1402.54","1402.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Osteo 12Mm Sht Mri","40000715","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","182","182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Osteo 10Mm Sht Mri","40000716","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","182","182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fbr Lsr Holmium","40000717","CDM","270","RC","","","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fbr Lsr Grnlght Xps","40000718","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","274.96","274.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"7Mm X 60Mm Balloon, 130Cm Cath","40000719","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1968.75","1968.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"0.018In X 300Cm Hi-Torque Comm","40000720","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applier Sut Clp For 2-0 3-0","40000721","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","653.38","653.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Spnl L45Mm Dia7Mm","40000722","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4731.56","4731.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Sacroiliac Jt Fus L55Mm","40000723","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4662.66","4662.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac Jt Fus","40000724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Dia4.75Mm","40000725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","828.07","828.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"0.35In X 275Cm Safari2 Guidew","40000726","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","945","945","","","","","","","","","","","","","Gross Charge Type: Standard"
"Awl Surg Dia3.8Mm Tapr Disp","40000727","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","325.5","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"8Fr X 35Cm Super Arrow-Flex Pe","40000728","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","186","186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surg Adj Disp Perla","40000729","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","447.62","447.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L14Mm Od3.5Mm","40000730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1857.11","1857.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Scr Spnl Perla","40000731","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","296.1","296.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L30Mm Dia3.5Mm Cerv","40000732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fx 1.25Mm 150Mm Thrd Tip","40000733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"12Mm Amplatzer Vascular Plug 2","40000734","CDM","278","RC","C1817","HCPCS","","","facility","both","","","","1248","1248","","","","","","","","","","","","","Gross Charge Type: Standard"
"14Mm Amplatzer Vascular Plug 2","40000735","CDM","278","RC","C1817","HCPCS","","","facility","both","","","","1248","1248","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 10 L Knee","40000736","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Ef Fem 10-11","40000737","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.6","2049.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L100Cm","40000738","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","44","44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 8Fr L90Cm Id2.9Mm","40000739","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","186","186","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.00Mm X 15Mm Balloon, 2.0Fr P","40000740","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 6Fr L10Cm Mini","40000741","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","244.58","244.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 9Fr L10Cm Periph","40000742","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","251.22","251.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guid L135Cm Od2.3Fr","40000743","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1013","1013","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L140Cm Blln","40000744","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L140Cm Blln","40000745","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L160Mm Dia9.5Mm Blu R","40000746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1909.95","1909.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia10Mm 130Deg","40000747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817","2817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia9Mm 130Deg","40000748","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3119.55","3119.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 5Mmx11Mmx11Mm","40000749","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1824.21","1824.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub W11Xh6Mm D11Mm","40000750","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1824.21","1824.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Spnl L45Mm Dia7Mm","40000752","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Spnl Sht 29Mm Bllt","40000753","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4134.9","4134.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L500Mm Dia4.75Mm Ant","40000754","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1589.7","1589.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss W14Xh5Mm D11Mm","40000755","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1720.95","1720.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Shth 6Fr L13Cm Ptfe","40000756","CDM","272","RC","C1892","HCPCS","","","facility","both","","","","163","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Shth 6Fr L25Cm Ptfe","40000757","CDM","272","RC","C1892","HCPCS","","","facility","both","","","","183","183","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000758","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000759","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000760","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000761","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"22Fr X 9Fr Gastric, 22Fr X 12F","40000762","CDM","272","RC","B4087","HCPCS","","","facility","both","","","","474.6","474.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Corneal W1Xl1.5Cm","40000763","CDM","278","RC","V2790","HCPCS","","","facility","both","","","","912.45","912.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm X 25Mm Balloon, 2.0/2.6F","40000764","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca 4Fr L150Cm Blln","40000765","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","693","693","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Nrv L30Mm Dia2-3Mm","40000766","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4893","4893","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Duodenal L120Mm Dia22Mm","40000767","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3479.7","3479.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 9 L Knee Cocr","40000768","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 9 R Knee Co","40000769","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 10 Nar L Knee","40000770","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 9 Std L Knee","40000771","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Cd","40000772","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.6","2049.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca 6Fr L75Cm Blln","40000773","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 6Fr L25Cm Dil","40000774","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","543.9","543.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 7Fr L25Cm Dil","40000775","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","543.9","543.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L150Cm Blln","40000776","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","774.9","774.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L150Cm Bl","40000777","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","774.9","774.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Cor Blln N-Compliant","40000778","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000779","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm Tip","40000780","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","3111.15","3111.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm Ti","40000781","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Mt L18Mm Dia9.5Mm Toe Ti","40000782","CDM","278","RC","C1817","HCPCS","","","facility","both","","","","888.3","888.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Mt Dia15Mm 2.5X3.5Mm","40000783","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3234","3234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr L110Cm Cor","40000784","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L260Cm","40000785","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1022","1022","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Vasc 3.2Fr L175Cm","40000786","CDM","272","RC","C1713","HCPCS","","","facility","both","","","","983","983","","","","","","","","","","","","","Gross Charge Type: Standard"
"7Mm X 40Mm Stent, 125Cm Delive","40000787","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Vascular 8 Fr 70 Cm","40000788","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","116","116","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L135Cm Blln","40000789","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","627.9","627.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L13Mm Dia3Mm Cath","40000790","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 8Fr L25Cm Dil","40000791","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","543.9","543.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W15Xl15Cm Polypr","40000792","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","318.15","318.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Sft-Vu Braid Renal 5F","40000793","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","4.2","4.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr L65Cm Gwire","40000794","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","4.2","4.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Valvuloplasty 9Fr","40000795","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","987","987","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Us 6Fr L120Cm 0.014In","40000796","CDM","272","RC","C1753","HCPCS","","","facility","both","","","","3806.25","3806.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm","40000797","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern L W4.1Xl6.2In R","40000798","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","478.8","478.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm Tip","40000799","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L180Cm","40000800","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","41","41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L260Cm","40000801","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","58","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph 6Fr L40Mm Dia7Mm","40000802","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1851.15","1851.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid L70Cm Id2.9Mm","40000803","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gd 90Cm 4Fr 1.5Mm Ckfl","40000804","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","186","186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 65Cm 7.5Mm 20Fr","40000805","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","1140","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer/Sheath","40000806","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","1140","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 45Cm 4.7Mm 12Fr","40000807","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","923","923","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Cath 90Cm 6.5Fr","40000808","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L195Mm Dia3.2Mm 3 Flut","40001001","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","183.72","183.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia4.5Mm Cort","40001002","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L301Mm 4.5Mm 14 H St","40001003","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2531.68","2531.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L34Mm Dia5Mm","40001004","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","369.54","369.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia5Mm","40001005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L65Mm Dia5Mm","40001007","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia5Mm","40001008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L440Mm Dia3Mm 85Deg","40001009","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","602.51","602.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L440Mm Dia3.5Mm 8Deg","40001010","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","632.81","632.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia5Mm Ti","40001011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","943.82","943.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia5Mm Ti","40001012","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im M L200Mm Dia10Mm","40001013","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6223.06","6223.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 8 L111Mm 12/14","40001014","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3241.88","3241.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od51Mm Id28Mm Fem","40001015","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia2.7Mm Cort","40001016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia4Mm Canc Ti","40001017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L16Mm Dia4Mm Self","40001019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504","504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L40Mm Ant Cerv Lev","40001020","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Lord Cerv Cage L","40001021","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4436.26","4436.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Lord Cerv Cage","40001022","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4358.7","4358.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L72Mm Dia4Mm Hd","40001023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L73Mm 2 H R Prox","40001024","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1231.88","1231.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L125Mm 7 H","40001029","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","852.71","852.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L159Mm Thk4.5Mm 6 H","40001030","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2376.18","2376.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L159Mm 4.5Mm 6 H","40001031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2376.18","2376.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 7 L114Mm Nk L37","40001032","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4061.43","4061.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Lord Cerv Cg Sm","40001033","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4436.26","4436.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L92Mm 4 Lev Ant","40001035","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 20Mm Dart-Fire Ti","40001036","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","701.4","701.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pncr 15Mm 24Mm 10Mm 146","40001037","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7926.19","7926.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 42Mm Dart-Fire","40001038","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","703.5","703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Periph Angio Vis Sel","40001039","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","317.1","317.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L195Mm 4.5Mm 8 H","40001040","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2423.07","2423.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L195Mm 4.5Mm 8 H","40001041","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2423.07","2423.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L54Mm Dia3.5Mm Tan","40001043","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.62","207.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L56Mm Dia3.5Mm Ti St","40001044","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.62","207.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L58Mm Dia3.5Mm Tan","40001045","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.62","207.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia2.5Mm Thrd","40001046","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia6.5Mm Hex","40001047","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.32","154.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia4.75Mm Hd","40001048","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","156.12","156.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bne L90Mm Dia10Mm G Ti","40001049","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","656.68","656.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L25Mm Dia6.5Mm Acet","40001050","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","85.63","85.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-9 Tib","40001051","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Gh","40001052","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Gh/Ps","40001053","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc H12Mm R Knee","40001054","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2111.36","2111.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L150Cm Blln","40001055","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bne L95Mm Dia10Mm G Ti","40001056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","637.56","637.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm Blln L60Mm","40001057","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm Blln L60Mm","40001058","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Tiss 13X13.5Cm 550Cc","40001060","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2126.25","2126.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L5Cm Dia10Mm","40001061","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4430.8","4430.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 10-11 Tib","40001062","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L67Mm 7 H Bilat Ss","40001063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","746.9","746.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Surg L88Mm Dia3.5Mm Sht","40001064","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","165.35","165.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L160Mm Dia6.5Mm Std","40001065","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od57Mm Id28Mm Fem","40001066","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","930.91","930.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L103Mm 5 H St R","40001068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","884.49","884.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L90Mm 6 H St Dst Tib","40001069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1215.81","1215.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L301Mm 14 H","40001070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2927.54","2927.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Surg Dia2.5Mm For Ext","40001071","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","165.35","165.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Drl Od6Mm Id5Mm Lng","40001072","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","177.49","177.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Dia4.5Mm Cort","40001073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L52Mm Dia4.5Mm Cort","40001074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L85Mm 6 H L Sup Clav","40001075","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1134.35","1134.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L214Mm Dia16Mm Cann","40001076","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2165.09","2165.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L230Mm 4.5Mm 10 H","40001078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2536.26","2536.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L336Mm 4.5Mm 16 H","40001079","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2816.81","2816.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia3.5Mm Thrd","40001080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","843.78","843.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia3.5Mm Thrd","40001081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia3.5Mm Thrd","40001082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia4Mm Thrd","40001084","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L48Mm Dia4Mm Thrd","40001085","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia4Mm Carb Disp","40001086","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","394.34","394.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia5Mm","40001087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","498.04","498.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia5Mm","40001088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","498.04","498.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L46Mm Dia5Mm","40001089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L45Mm Dia5Mm 3.5Mm","40001090","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L42Mm Dia4.5Mm Cort","40001092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L44Mm Dia4.5Mm Cort","40001093","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L48Mm Dia4.5Mm Cort","40001094","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L370Mm 4.5Mm 18 H St","40001095","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2749.56","2749.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia5Mm","40001096","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia5Mm Cort Ti","40001097","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia5Mm Cort Ti","40001098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L65Mm Dia5Mm Cort Ti","40001099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L48Mm Dia5Mm","40001100","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L135Cm Blln","40001101","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curette Surg L12In Tip Sz 1","40001102","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","146.25","146.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curette Surg L12In Tip Sz 2","40001103","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","135.8","135.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curette Surg L12In Tip Sz 3","40001104","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","135.8","135.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curette Surg L12In Tip Sz 4","40001105","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","143.95","143.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Curette Surg L12In Tip Sz 5","40001106","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","145.53","145.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"7Mm X 40Mm Balloon, 80Cm Shaft","40001107","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surg Dia6.5Mm Cann Hd","40001108","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut Cresc Nit Wre Loop","40001110","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","356.16","356.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imp Contour Bn Void Fiil/Strp","40001111","CDM","278","RC","C9362","HCPCS","","","facility","both","","","","2189.5","2189.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"13Mm X 5Cm X 120Cm Viabahn End","40001112","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4389","4389","","","","","","","","","","","","","Gross Charge Type: Standard"
"7Mm Dia X 10Cm, 120Cm Catheter","40001113","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4977","4977","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm X 100Mm Balloon, 150Cm S","40001114","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","212","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L35Mm Dia4.7Mm Cort","40001115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","856.8","856.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L9.25In","40001116","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","45.05","45.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L39Mm Dia7X11Mm","40001118","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4411.31","4411.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia3.5Mm","40001119","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","595.66","595.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L24Mm Od3.5Mm","40001120","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1820.7","1820.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L20Mm Dia9Mm Ant","40001121","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","589.89","589.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L59Mm 7 H Bilat Ss","40001122","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","983.3","983.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia10.35Mm G","40001123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","925.09","925.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L95Mm Dia10.35Mm","40001124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","872.73","872.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell, Sht 25 Mm, Flarehawk 9","40001126","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 25Mmx9-12Mm","40001127","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Cran 200 To 325Sqcm","40001128","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","40266.75","40266.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 10 L148Mm Nk L36Mm","40001130","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W22Xl109Mm Xln Std","40001131","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2110.77","2110.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L77Mm 3 H R","40001132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","860.64","860.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Nominal 8Mmx16Mm Post Dl","40001134","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4411.31","4411.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteocyte Allograft Fiber Bone","40001136","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3305.61","3305.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nerve L15Mm Dia2Mmp","40001137","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2776.5","2776.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nrv L10Mm Dia2Mm","40001138","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty Sh 4Fr 60","40001139","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W17.5Xl152 Thk5.2 S","40001140","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","905.44","905.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L345 Dia9","40001142","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L38 Dia2.7 Dia5","40001143","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.54","73.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Dia28 Neck L+0","40001144","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","926.25","926.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Intro 18/20 Echoblast","40001145","CDM","272","RC","A4215","HCPCS","","","facility","both","","","","160.96","160.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22 Dia2.4 Titanium","40001146","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5Th Metatarsal Hook","40001147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3188.75","3188.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L30 Dia2.5 Head","40001148","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95 Dia5 Cortical","40001149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90 Dia5 Cortical","40001150","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","809.68","809.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Femoral Retrograde 10 440","40001151","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5755.18","5755.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Medullary Nails L64 5","40001152","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","809.68","809.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L40 Dia2.7 Dia5","40001153","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.54","73.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 12.8Mm Sterile","40001154","CDM","278","RC","A4649","HCPCS","","","facility","both","","","","2219.36","2219.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radial Head W/ 22 Hd 6.5 Stm","40001155","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4060.55","4060.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs1 Left","40001156","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3255.53","3255.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs1 Right","40001157","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L45 Dia2.7 Dia5","40001159","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.54","73.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia M W3Xl5In Right In","40001160","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","451.71","451.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic L150Mm Di","40001161","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","45","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3 Mini Foot Ank","40001162","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L80Cm Bal","40001163","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","226.84","226.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L38 Di3.5 Head Stan","40001164","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","132.75","132.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90 Di3.5 Head Stan","40001165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","128.79","128.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95 Di3.5 Head Stan","40001167","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","128.79","128.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Di4.5 Head","40001168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","146.25","146.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L65 Dia3.5 Cervicol","40001169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L54 Di4.5 Head Stan","40001170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","146.25","146.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L58 Di4.5 Hex Head","40001171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","146.25","146.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Left Supra Pectinea","40001172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3411.45","3411.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation L150 Dia3.2","40001173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.06","291.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L285Mm Od2.5Mm Calib","40001175","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","799.47","799.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surgical L12 Fixed Dispo","40001176","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","739.2","739.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Dia2 Cortical","40001177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.43","73.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L81 12 Hole Stain S","40001178","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.66","726.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L81 12 Hole Stain S","40001179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Anatomic Cervical Cage Larg","40001180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4383.76","4383.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Tibial Cd Fe","40001181","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L135Cm Ba","40001183","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L285Mm Dia3.1Mm Calib","40001184","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","720.09","720.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Drill Universal For 2 P","40001185","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","688.82","688.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver Surgical L330 Di6","40001187","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","598.46","598.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L400 Dia9","40001188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3306.47","3306.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L118 6 Hole Right","40001189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1880.26","1880.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 10Fr L45 Id3.4","40001191","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","189.1","189.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 10Fr L45 Dia3.4","40001192","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","186","186","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 1Cc Demi","40001193","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","338.5","338.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Od9Mm Lng Ti","40001194","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4343.46","4343.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L150 4 Ba","40001195","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","420.71","420.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L35 Dia4.75 Head","40001196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","159.74","159.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L15 Dia4.75 Head","40001197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150.7","150.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Drill Dia1/8In Quick Relea","40001198","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","209.12","209.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 5 Stand","40001199","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L40 Dia7 8Fr","40001200","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","994.5","994.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L80 Dia7 8Fr","40001201","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","994.5","994.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 Hole Left Distal","40001202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1422.22","1422.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 3 L102 Neck","40001203","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3777.25","3777.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fixation Proximal Interpha","40001204","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1871.1","1871.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Surgical Sm L46 Cerclag","40001205","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","4347.73","4347.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Surgical L60Mm Cerclage","40001206","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","4347.73","4347.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Tibial G-H","40001207","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L65 Dia5 Unicortica","40001209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.11","324.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L75 Dia5 Unicortica","40001210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.11","324.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Screws Medullary 42","40001211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Screws Medullary 40","40001212","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od32 +0 Offse","40001213","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 8 L140 Neck","40001214","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3135.82","3135.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Surgical 4.5Mm Cannulated","40001215","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","349.65","349.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L45 Dia4.5 Tita","40001217","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2753.35","2753.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurostimulator Lead L70 5","40001218","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L380 Dia","40001219","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L92 4 Hole Left Dis","40001220","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1189.01","1189.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acetabular Size D Dia32","40001221","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1243.74","1243.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fx 1.6Mm 150Mm Krsh Ti","40001222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","20.4","20.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conduit Aortic Valve 27 Bovine","40001223","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","21000","21000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Size C Od48Mm","40001225","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acetabular Size C Dia46","40001226","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1761.76","1761.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acetabular Trdnt X3 10","40001227","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Accolade Ii V40","40001228","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2828.13","2828.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acetabular Trident Ii 60","40001229","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1710.45","1710.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Summit 2 12/14 St","40001230","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2718.9","2718.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bipolar Slfcntr Od53 Id28","40001231","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 0.5Cc Dbm Ptty","40001233","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","193.96","193.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 5Mm 1.35Mm 38Mm","40001234","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Cmplt Opn Rmr Asmb","40001235","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1992.38","1992.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 10Mm 360Mm Fem Piriformis","40001236","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"38Mm Locking Screw","40001237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","811.66","811.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"60Mm Locking Screw","40001238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"80Mm Locking Screw","40001239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.71","805.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Xtrnfx 105Mm Fem Nk Sys","40001241","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 110Mm Antirotate Strl","40001242","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","429.87","429.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 18Mm Ti T8 St","40001243","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","224.22","224.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Ti 2.4/2.7 Mm Scr 5X12","40001244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2114.52","2114.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 44Mm Ti T25 St","40001245","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001246","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 79Mm 7Mm 11Mm 7Fr","40001247","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4823.44","4823.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 79Mm 9Mm 13Mm 8Fr","40001249","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4823.44","4823.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Wnd Bvn Clgn Gag","40001250","CDM","278","RC","Q4114","HCPCS","","","facility","both","","","","3110.11","3110.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac Jt L70Mm","40001251","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 335Cm .014In","40001252","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"6  Degree Lordotic Shell","40001253","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4382.44","4382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 5Cc Allgrft Fbr","40001254","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1919.93","1919.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H21Mm Od50Mm Id46Mm","40001255","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2256","2256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum Univ Std L122Mm","40001256","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4521.57","4521.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Truclear Dense Tissue Shaver P","40001258","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1198.5","1198.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Truclear Elite Hysteroscope Se","40001259","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","37.5","37.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Ef","40001260","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W24.4Xl51.3Mm Sht","40001261","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1594.38","1594.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L20Mm Dia2Mm Dst","40001262","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L26Mm Dia2.5Mm Hnd","40001263","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L16Mm Dia2.5Mm Dst","40001264","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L26Mm Dia2.5Mm Dst","40001266","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 9 Std R Knee","40001267","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 8 L117Mm Nk L37Mm","40001268","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001269","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","2432.72","2432.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L36Mm 2 Lev Ant","40001270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor/Screw Bn/Bn,Tis/Bn","40001271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","910.2","910.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L3.3Cm Dia26Mm","40001272","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Driver Surg Dia2.5Mm M Hex","40001274","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","694.26","694.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc H12Mm L Knee","40001275","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib G-H/ Fem","40001276","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L13Mm Dia3.5Mm Cort","40001277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia3.5Mm Cort","40001278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L16Mm Dia2Mm Dst","40001279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L18Mm Dia2Mm Dst","40001280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L22Mm Dia2Mm Dst","40001282","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L18Mm Dia2.5Mm Dst","40001283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L22Mm Dia2.5Mm Dst","40001284","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L143Cm Blde","40001285","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1496.25","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W19.5Xl51Mm 9 H R","40001286","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1252.22","1252.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Art Wrk L110Cm L60Mm","40001287","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","3609.38","3609.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2Mm Cort Ss","40001288","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L65Mm Dia2Mm Mini Ss","40001289","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","98.82","98.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L157Mm 9 H St L Dst","40001290","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1495.92","1495.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Nephstmy L26Cm Cath","40001291","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","260.78","260.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blln Dil 7.5Fr L180Cm","40001292","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","756.84","756.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diag Guidewire 0.038Cmx150Cm","40001293","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","165.13","165.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia3.5Mm Brnz","40001294","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dil 7.5Fr L180Cm Blln","40001295","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","722.57","722.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Distal Lateral Femur Plate Rig","40001296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4730.91","4730.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bne L120Mm Dia10Mm G Ti","40001297","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","478.17","478.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L110 Dia6.5 Thread","40001298","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","143.32","143.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L36 Dia4 Thread L9","40001299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","375.58","375.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40 Dia4 Long Tit","40001300","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","375.58","375.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L315Mm Dia4.3Mm Calib","40001301","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","740.88","740.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L315Mm Dia2Mm W/ Drl","40001302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230.4","230.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L315Mm Dia3.2Mm Calib","40001303","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","714.42","714.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L120Mm Dia6.4Mm Blu","40001304","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","429.87","429.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L48Mm Dia5Mm Ti Ally","40001305","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Dia5Mm Ti Ally","40001306","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L55Mm Dia5Mm Ti Ally","40001308","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L343Mm 16 H Ti R Dst","40001309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4730.91","4730.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L24Mm Dia5Mm Ti Ally","40001310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.78","570.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L26Mm Dia5Mm Ti Ally","40001311","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.78","570.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L34Mm Dia5Mm Cort Ti","40001312","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.78","570.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia5Mm Cort Ti","40001313","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.78","570.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia5Mm Cort Ti","40001314","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.78","570.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia5Mm","40001316","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","659.61","659.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia5Mm","40001317","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","659.61","659.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia4.5Mm Cort","40001318","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","153","153","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia4.5Mm Std","40001319","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","153","153","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire 1.25Mm X 150Mm","40001321","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","684.04","684.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occlusion Balloon Cath Set","40001324","CDM","272","RC","","","","","facility","both","","","","360.94","360.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligator 2.8Mm 8.6-11.5Mm Sss7","40001325","CDM","272","RC","","","","","facility","both","","","","344.53","344.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amplantz Dilation Set 8-30Fr","40001328","CDM","272","RC","","","","","facility","both","","","","619.93","619.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephromax High Pressure Nephro","40001332","CDM","272","RC","","","","","facility","both","","","","801.99","801.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone Hip Prep Kit","40001347","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101","101","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 2.0Mm","40001348","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 2.0Mm","40001350","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Sensor Finger Clearsight","40001351","CDM","271","RC","","","","","facility","both","","","","1023.75","1023.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retriever Suture Hewson","40001352","CDM","271","RC","","","","","facility","both","","","","267.51","267.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Sensor Finger Clearsight","40001353","CDM","271","RC","","","","","facility","both","","","","1023.75","1023.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Sensor Finger Clearsight","40001354","CDM","271","RC","","","","","facility","both","","","","1023.75","1023.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia4.5Mm Std","40001355","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","153","153","","","","","","","","","","","","","Gross Charge Type: Standard"
"207.660 Synthes 4Mm Cannulated","40001358","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1765.14","1765.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gel Port","40001359","CDM","272","RC","","","","","facility","both","","","","704.19","704.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"8Fr Groshong Cv Cath 8Fr","40001361","CDM","272","RC","","","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L35Mm Dia5Mm Cort Ti","40001362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Artegraft Cardiovasc Coll L30","40001363","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2085.56","2085.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Incision Mgmnt Peel","40001365","CDM","272","RC","","","","","facility","both","","","","1678.26","1678.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Canister 45Ml","40001366","CDM","272","RC","","","","","facility","both","","","","92.5","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Dressing Customized","40001367","CDM","272","RC","","","","","facility","both","","","","1112.5","1112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Norian Drillable Fast Set Putt","40001368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4188.85","4188.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia5Mm Cort Ti","40001370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.012 Synthes 3.5 Lcp Pla","40001371","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3845.63","3845.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.030 Synthes 3.5 Lcp Pla","40001373","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3459.75","3459.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.254 Synthes 1.5 Phalang","40001377","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1188.75","1188.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.224 Synthes 5.0Va Lck S","40001379","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.13","559.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.228 Synthes 5.0 Va Ang","40001381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.13","559.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.232 Synthes 5.0 Va Ang","40001383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.13","559.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.655 Synthes 5.0 Cann Va","40001385","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","759.94","759.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.655 Synthes 5.0 Cann Va","40001386","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","759.94","759.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.665 Synthes 5.0 Cann Va","40001387","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","759.94","759.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"292.71 Synthes  K Wire 1.6Mm X","40001388","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","654.43","654.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"394.796 Synthes 1Mm Carbon Fib","40001390","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1065","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"394.799 Synthes 11Mm Carbon Fi","40001391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1065","1065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ares Antibiotic Impregnated Ca","40001392","CDM","272","RC","","","","","facility","both","","","","1496.99","1496.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Foley Red Ltx 2Wy5Cc","40001393","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","47.61","47.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clevercut Spinctertome","40001394","CDM","272","RC","","","","","facility","both","","","","1257.5","1257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Prolene Soft 3X6","40001395","CDM","272","RC","","","","","facility","both","","","","460.69","460.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Prolene 6X6","40001396","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Prolene Soft Poly","40001397","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","946.25","946.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Catheter Connector - Rig","40001399","CDM","272","RC","","","","","facility","both","","","","212.5","212.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capio Suture Device Slim","40001400","CDM","272","RC","","","","","facility","both","","","","1546.26","1546.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh-Tot System Solyx Sis","40001401","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3531.63","3531.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Gyn 24 X 4 Cm","40001402","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1799.44","1799.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Gyn 24 X 4 Cm Contour","40001403","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2356.25","2356.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Gyn 27 X 4 Cm","40001404","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1980.56","1980.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prass Paired Emb Electrode","40001405","CDM","272","RC","","","","","facility","both","","","","371.47","371.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maxcore Biopsy Instrument","40001407","CDM","271","RC","","","","","facility","both","","","","98.28","98.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia5Mm Cort Ti","40001409","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Std 54Mm Ss 2.4Mm Scr 6","40001410","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2196.7","2196.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"351.27 Synthes Drill Bit 300Mm","40001412","CDM","272","RC","","","","","facility","both","","","","1109.97","1109.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"456.305S Synthes 11.0Mm Helica","40001413","CDM","272","RC","","","","","facility","both","","","","1187.72","1187.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.820 Synthes 3.5Mm Screw","40001415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.81","222.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2066.35","2066.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureteral Access Sheath 12/14 X","40001417","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","49.25","49.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.307 Synthes 2Mm Screw","40001418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.06","154.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2Mm 10Mm","40001419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","203.5","203.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.4Mm 5Mm","40001420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.436.01 Synthes Screw","40001421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.4Mm 12Mm","40001423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.444.01 Synthes 2.4Mm Sc","40001424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.446.01 Synthes 2.4Mm Sc","40001425","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.638.01 Synthes 2.4Mm Sc","40001426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","490.88","490.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.640.01 Synthes 2.4Mm Sc","40001427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.25","530.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.642.01 Synthes 2.4Mm Sc","40001428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.25","530.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.644.01 Synthes 2.4Mm Sc","40001429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.25","530.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.233.01 Synthes 3Mm Scre","40001431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.63","275.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.234.01 Synthes 4Mm Scre","40001432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.63","275.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.391 Synthes Med Std Box","40001433","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.5","877.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"03.503.451 Synthes J-Latch Dri","40001434","CDM","272","RC","","","","","facility","both","","","","569.63","569.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"03.503.477 Synthes J-Latch Dri","40001435","CDM","272","RC","","","","","facility","both","","","","658.88","658.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.522E Synthes 2.4Mm Cortex","40001436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.524E Synthes 2.4Mm Cortex","40001437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.526E Synthes 2.4Mm Cortex","40001438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.528E Synthes 2.4Mm Cortex","40001439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.530E Synthes 2.4Mm Cortex","40001440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.532E Synthes 2.4Mm Cortex","40001441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.536E Synthes 2.4Mm Cortex","40001442","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.538E Synthes 2.4Mm Cortex","40001443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"401.540E Synthes 2.4Mm Cortex","40001444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","291.38","291.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"306.755 Synthes Mandible Lag S","40001445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"306.766 Synthes J-Latch Drill","40001446","CDM","272","RC","","","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"209.735 Synthes 7.3Mm Screw","40001447","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","752.69","752.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"412.134 Synthes 3.5Mm Screw","40001449","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.63","346.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.324 Synthes 2Mm Screw","40001451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","392.7","392.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.363.97 Synthes 2Mm Screw","40001452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.54","120.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.364.97 Synthes 2Mm Screw","40001453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.54","120.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.353 Synthes 1.3Mm Y Pla","40001454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1190.14","1190.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.240.060 Synthes 3.7Mm Screw","40001456","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.16","546.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.240.080 Synthes 3.7Mm Screw","40001457","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.16","546.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.240.090 Synthes 3.7Mm Screw","40001458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.16","546.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"212.325 Synthes 3.5Mm Screw","40001459","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","388.97","388.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.682 Synthes 2.4Mm Screw","40001460","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1356.75","1356.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.005 Synthes 1.3Mm Corte","40001461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.06","154.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.204 Synthes 1.5Mm Screw","40001462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","379.31","379.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.352 Synthes 1.3Mm Plate","40001464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","379.31","379.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.684 Synthes 2.4Mm Plate","40001465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1382.76","1382.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.006 Synthes 1.3Mm Screw","40001466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.06","154.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.690 Synthes 2.4Mm Plate","40001467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1257.75","1257.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.691 Synthes 2.4Mm Plate","40001468","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1356.75","1356.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.354 Synthes 1.3Mm Plate","40001469","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.65","1370.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"212.131 Synthes 3.5Mm Screw","40001470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","376.72","376.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Acc 12Fr Dilation Cnt","40001472","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","45","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.124.411S Synthes 4.5Mm Plat","40001473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.94","3189.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.250 Synthes 5Mm Screw","40001474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","564.38","564.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.772 Synthes 4/3Mm Screw","40001475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.94","412.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.038.085S Synthes Tfn Screw","40001476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1749.5","1749.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"03.037.002 Synthes Tfn Drill B","40001477","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2026.97","2026.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.037.023S Synthes 10Mm Nail","40001478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4273.54","4273.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.111.621S Synthe 45Mm Plate","40001479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2096.09","2096.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.113 Synthes 1.3Mm Screw","40001480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","341.38","341.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.260 Synthes 1Mm Plate","40001481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1132.69","1132.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.264 Synthes 1Mm Plate","40001482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.72","1516.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.158 Synthes Oblique Str","40001483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1236.65","1236.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.526 Synthes 1Mm Screw","40001484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.527 Synthes 1Mm Screw","40001485","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.528 Synthes 1Mm Screw","40001486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.529 Synthes 1Mm Screw","40001487","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.530 Synthes 1Mm Screw","40001488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.110 Synthes 1.3 Mm Scre","40001490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","341.38","341.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.214.108 Synthes 1.5Mm Screw","40001491","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","145.88","145.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.310 Synthes 2Mm Screw","40001492","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","416.26","416.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.268 Synthes 1Mm Plate","40001493","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.81","1516.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.127.310 Synthes 3.5Mm Plate","40001494","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3489.91","3489.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.111 Synthes Bone Screw","40001495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","341.38","341.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.309 Synthes Bone Screw","40001496","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","392.7","392.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"338.10 Synthes Drill Bit","40001498","CDM","272","RC","","","","","facility","both","","","","1139.89","1139.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"214.048 Synthes 4.5Mm Screw","40001499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","238.75","238.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.786 Synthes Schanz Screw","40001500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","483.9","483.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"208.080 Synthes 7Mm Screw","40001501","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","414.75","414.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"456.301S Synthes 11.0Mm Helica","40001502","CDM","272","RC","","","","","facility","both","","","","1187.72","1187.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.438.01 Synthes Screw","40001503","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.503.646.01 Synthes 2.4Mm Sc","40001504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.25","530.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.150 Synthes 1.3Mm Plate","40001506","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1127.2","1127.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.206 Synthes 1.5Mm Screw","40001507","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","379.31","379.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.360 Synthes 1.3Mm Plate","40001508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.29","1370.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"245.023 Synthes 3.5Mm Plate","40001509","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","897.83","897.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.214.118 Synthes Bone Screw","40001510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","392.7","392.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.206.226 Synthes 3.5Mm Screw","40001511","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5417.19","5417.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L80Mm Dia5Mm Cort Ti","40001512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Myriad Specimen Collec","40001515","CDM","272","RC","","","","","facility","both","","","","156.25","156.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Brainpath Sheath 13.5X","40001516","CDM","272","RC","","","","","facility","both","","","","1958.91","1958.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Brainpath Sheath 13.5X","40001517","CDM","272","RC","","","","","facility","both","","","","1958.91","1958.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Brainpath Sheath 13.5X","40001518","CDM","272","RC","","","","","facility","both","","","","1958.91","1958.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Myriad Handpiece 13Gx1","40001519","CDM","272","RC","","","","","facility","both","","","","5390.63","5390.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Myriad Handpiece 11Gx1","40001520","CDM","272","RC","","","","","facility","both","","","","5390.63","5390.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.381.97 Synthes 2.0 Cortex","40001522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.54","120.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.382.97 Synthes 2.0 Cortex","40001523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.54","120.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.110.009 Syntehs Lcp Plate","40001524","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3462.84","3462.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.110.109 Synthes Lcp Plate","40001525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3462.84","3462.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.038.325 Synthes Helical Bla","40001526","CDM","272","RC","","","","","facility","both","","","","1697.8","1697.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.038.330 Synthes Helical Bla","40001527","CDM","272","RC","","","","","facility","both","","","","1697.8","1697.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.675 Synthes 5.0 Lock Sc","40001534","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","712.72","712.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.650 Synthes 5.0 Lock Sc","40001535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","712.72","712.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.026 Synthes 3.5 Lcp Pla","40001538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2791.75","2791.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum X-Artc Dst L 8H","40001540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2964.92","2964.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.034 Synthes 3.5 Lcp Pla","40001541","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3198.68","3198.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.670 Synthes 5.0 Lock Sc","40001542","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","723.22","723.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.014 Synthes Lcp Distal","40001543","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3198.68","3198.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.220 Synthes 5.0 Lock Sc","40001548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","532.43","532.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.231.222 Synthes 5.0 Lock Sc","40001549","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","532.43","532.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia5Mm Cort Ti","40001550","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.5","661.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia14Mm Lng","40001551","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4343.46","4343.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm 125Deg","40001552","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +5Mm Offset","40001553","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","913.14","913.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent, Non-Coa/Non-Cov W/Del","40001555","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm Dia8Mm Cath","40001556","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Carotid L40 Unconstrn 9","40001557","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3142.13","3142.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Cereb Protct 6Fr L95Cm","40001558","CDM","278","RC","C1884","HCPCS","","","facility","both","","","","5250","5250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L79 Dia11X16","40001559","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4630.5","4630.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femorl 10-12","40001560","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001561","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3425.63","3425.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrex Suture Anchor Sm. Join","40001563","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","952.72","952.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrex Internal Brace Ligamen","40001564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2363.85","2363.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obtryx-Ii Halo Urethral Suppor","40001565","CDM","272","RC","C1771","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Urteral Stent 6X22","40001566","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","289.41","289.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia2 Aqua Tit","40001569","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"3 Dose Cmpct Vac Cemnt Mix Sys","40001572","CDM","272","RC","","","","","facility","both","","","","478.85","478.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Stylet","40001573","CDM","272","RC","","","","","facility","both","","","","956.25","956.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Pt Tracker Non Invasiv","40001574","CDM","272","RC","","","","","facility","both","","","","519.75","519.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12 Dia2.4 Cortical","40001575","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","410.55","410.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14 Dia2.4 Cortical","40001576","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","410.55","410.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar L3.3Cm Od23Mm","40001577","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24 Dia2 Sm Aqua","40001578","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","339.15","339.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 Hole Straight 3Di","40001579","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","668.85","668.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14 Dia2 Titanium S","40001580","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.3","113.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Va Lcp","40001581","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.38","3189.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Va Lcp Xl","40001582","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2692.5","2692.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ureteral Laser 7.1Frx","40001583","CDM","278","RC","C1758","HCPCS","","","facility","both","","","","45.35","45.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio Ad Ped 5Fr","40001584","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr L65Cm Gwire","40001585","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Diag 5Fr L65Cm","40001586","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Cor Blln N-Compliant","40001587","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","225","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Cor Blln N-Complian","40001589","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Valvuloplasty 9Fr","40001590","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","138.23","138.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia12Mm Dst","40001591","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","187.99","187.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ureth 20Fr 30Cc Blln","40001592","CDM","272","RC","A4340","HCPCS","","","facility","both","","","","352.48","352.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm Blln L40Mm","40001593","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","172.25","172.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L420 Dia11","40001594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L3.3Cm","40001595","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L110X85 Dia2 2 Flute","40001597","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","225.28","225.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Embolization L190 Di7.2","40001598","CDM","278","RC","C1884","HCPCS","","","facility","both","","","","1819.13","1819.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L135 20 5","40001599","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16 Dia4.5 Self","40001600","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504","504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle Shaft 2.7 Xl","40001601","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L400 Dia9","40001602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2692.5","2692.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W9Xl81 Thk1Mm 7 Hl","40001603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3119.31","3119.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L60 7 Hole Bilatera","40001605","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.31","307.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L47 7X2 Hole Left","40001606","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1152.6","1152.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs3 Right","40001607","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2676.5","2676.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W10.1Xl112 Thk3.5","40001608","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","932.86","932.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L400 Dia11","40001609","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L380 Dia11","40001610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2686.2","2686.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95 Dia6.5 Thread","40001611","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","286.64","286.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 150 40 4","40001613","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","385.1","385.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od32 +2.5 Offset","40001614","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2128.64","2128.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 8 L140 Neck","40001615","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 10 L160 Od12","40001616","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4061.43","4061.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od32 -2.5 Offset","40001617","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2148.92","2148.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Femoral Od14 Universal","40001618","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","270.84","270.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 8 L135 Od11","40001619","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2345.61","2345.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor - Alexis Med Flexibl","40001621","CDM","272","RC","","","","","facility","both","","","","129.72","129.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload Stapler Tk 5 Titanium Q","40001622","CDM","272","RC","","","","","facility","both","","","","125","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Suturing Rd180 Standard","40001623","CDM","272","RC","","","","","facility","both","","","","615.44","615.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Suturing Ti-Knot","40001624","CDM","272","RC","","","","","facility","both","","","","477.75","477.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Prolene 30X30Cm","40001625","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","271.43","271.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Prolene 5X30Cm","40001626","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","127.69","127.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Prolene 8X15Cm","40001627","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","123.26","123.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monopolar Stimulator Probe - P","40001628","CDM","272","RC","","","","","facility","both","","","","319.2","319.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Light Pipe - Stryker","40001629","CDM","272","RC","","","","","facility","both","","","","940.95","940.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Stm Ld Nevro Anch N300","40001630","CDM","278","RC","C1788","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Nrstm 50 Cm Nevro 5Mm Spc","40001631","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","2066.4","2066.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vivigen Forable Cellular Bone","40001632","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1070","1070","","","","","","","","","","","","","Gross Charge Type: Standard"
"Speedtitam Se-1515-Ti","40001633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2539","2539","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od36 -2.5 Offset","40001634","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2148.92","2148.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs1 Right S","40001635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L52 7 Hole Bilatera","40001636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","428.42","428.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L59 8 Hole Bilatera","40001637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","428.42","428.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L84 10 Hole Bilater","40001638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","687.31","687.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs2 Right","40001639","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2979.9","2979.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Ext Fix Drv W/ Qc For","40001640","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","268.8","268.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L26Mm Dia5Mm Cort Ti","40001641","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.8","373.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L55Mm Dia5Mm Cort Ti","40001642","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.8","373.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia5Mm Cort Ti","40001643","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.8","373.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L43.5Mm 3 H St Bilat","40001644","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","531.3","531.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scissors Endoscp Robotic Pott","40001645","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50 Dia5.5 Titanium","40001646","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2597.5","2597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Size E Id36","40001647","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2027.28","2027.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 8 Hole Ankle Stain","40001648","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia3.5 Cortical","40001649","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.12","90.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L177 10 Hole Proxim","40001650","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2443.1","2443.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L80 20 6","40001651","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","226.84","226.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L135 80 7","40001652","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia5Mm Ss St","40001653","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","519.75","519.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia5Mm Ss St","40001654","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","519.75","519.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L26Mm Dia5Mm Cndyl","40001655","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","317.1","317.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L25Mm Dia5Mm Cndyl","40001656","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","431.55","431.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guid Surg Prox Fem For Hamr","40001657","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","910","910","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver Surg Lng Sd40","40001658","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","636.3","636.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia11.5Mm Hllw","40001659","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","405.3","405.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 Dia7 Polyaxia","40001660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L136Mm Prox Fem","40001661","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","791.7","791.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Protct L118Mm Dia16Mm","40001662","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","889.35","889.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaft Scrdrvr L250Mm","40001663","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","261.45","261.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L35 Od7 Pedicle","40001664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia6.5Mm Sht","40001665","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","301.35","301.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia4Mm Hum Blu","40001666","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L32Mm Standard Bi","40001667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L34Mm Standard Bi","40001668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L160Mm Dia8Mm C","40001669","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","209","209","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.25Mm X 20Mm Balloon, 2.0Fr P","40001670","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L142 6 Hole Right","40001671","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.16","1516.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handle Inserter Titanium Silic","40001672","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","636.66","636.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Lateral Cs2","40001673","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2521.25","2521.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Medial Left","40001674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.38","3189.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Humeral L122 Dia9 Stad","40001675","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4521.57","4521.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L135 9 20","40001676","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Shaft Cs2 L","40001677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2979.9","2979.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L73Mm 10 Hole Bilat","40001678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","428.42","428.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L58Mm 3X7 Hole Bila","40001679","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","901.85","901.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 Cs3 Left","40001680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2676.5","2676.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Size 2 L8Mm","40001681","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1567.91","1567.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 70 7 3D","40001682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4869.38","4869.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L150 200","40001683","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2750","2750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 Dia4 Thread 10","40001684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 D4 Thread 14L","40001685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L55 Od7 Pedicle","40001686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L73Mm 3 Hole Right","40001687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","803.88","803.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M L64 Sterile Right","40001688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1806.23","1806.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Dia2.7 Metaphys","40001689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L44 Dia2.7 Metaphys","40001690","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 5.0","40001691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","224.88","224.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Module Sterilization For 2.4Mm","40001692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.28","1012.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L98Mm 8H 3Rd Tblr","40001693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili 10Fr L7Cm Chn 4.2Mm","40001694","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","290.16","290.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreas L5Cm Od5Fr","40001695","CDM","278","RC","C1877","HCPCS","","","facility","both","","","","227.48","227.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10 Dia2.7 Cort Tit","40001696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.84","207.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle 2.7 S3 Left Ss","40001697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1667.54","1667.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia3.5Mm Thrd","40001698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw B0Ne L48 D3.5 12 Sht","40001699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L48 D3.5 19","40001700","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L44Mm Dia3.5Mm Thrd","40001701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","796.24","796.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crew Bne L56Mm Dia2.7Mm","40001702","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Sm L34Mm Dia2.7Mm Hd","40001703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Sm L36Mm Dia2.7Mm Hd","40001704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia2.4Mm Cort","40001705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","111.73","111.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L36Mm Dia2Mm Cort Ss","40001706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.43","73.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L207Mm 12 H St L Prox","40001707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2718.41","2718.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W21.6Xl56.6Mm Std R","40001708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.13","1504.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L24Mm Dia2.5Mm Ft","40001709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor/Screw Bn/Bn,Tis/Bn","40001710","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3543.75","3543.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Breast Tissue 375Cc S","40001711","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2756","2756","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.9Mm For Sft Anchr","40001712","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","319.2","319.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penile Prosthesis Standard","40001713","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reservoir Penile Prosthess 125","40001714","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","3211.69","3211.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cylinder Penile Prosthesis L18","40001715","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","14621.25","14621.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L42 Dia3.5 Shrt 11","40001716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L48 Dia4 Thread 12","40001717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50 Dia4 Shrt 13","40001718","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femorl 10-11","40001719","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 3Cc Past","40001720","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1105.05","1105.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3.7 With 0.25 Squ","40001721","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","687.83","687.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 4Cc Calc","40001722","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3327.19","3327.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L100Mm Dia7Mm Hdlss","40001723","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2032.5","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L105Mm Dia7Mm Hdlss","40001724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2032.5","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 D5.5 4.75","40001725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2582.81","2582.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50 5.5 4.75","40001726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2582.81","2582.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 D6.5 4.75","40001727","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2582.81","2582.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30 D3 12 Thred Tit","40001728","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angiographic 5 110 3","40001729","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","317.1","317.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angiography 5 L65","40001730","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","327.97","327.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L L70 Sterile Left","40001731","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1715.24","1715.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia2.5 Tit 8","40001732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Dia2.5 Tit 14","40001733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 Dia2.5 Tit 7","40001734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia3 Long 8","40001735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22 Dia3 Long 9","40001736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24 Dia3 10 Tit","40001737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular L315 D0.014","40001738","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplt Shldr Sm Augmented","40001739","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3445.31","3445.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm L Fem","40001740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L280Mm Dia8Mm C","40001741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","209.46","209.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura W1Xl3In Celos","40001742","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","853.44","853.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L100Mm Od5.4Mm Perc","40001743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Patella Plate 2.7 Ant","40001744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3008.78","3008.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ercp 7Fr L240Cm Styl","40001745","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","162","162","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Bne 2.5Cc Dbm Crush Mix","40001746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2640","2640","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L60 D4.75 Cobalt","40001747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","940.5","940.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Implant 4.75X19.1 Secon","40001748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1087.5","1087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Artificial H5Mm 17X17Mm F","40001749","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7512.75","7512.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Introdcer 8Fr L25 Rdpq","40001750","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","732.06","732.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod External Fixation L320 D8","40001751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.03","222.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Patella Plate 2.7 Tit","40001752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3309.8","3309.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Va Locking Patella Plate 2.7","40001753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.31","3189.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Size 5 Total Ankle","40001754","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","14215.69","14215.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Talar Dome Flatcut 3D","40001755","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","15986.86","15986.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ankle Joint Size +4 7M","40001756","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4979.63","4979.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Cardiac Dual Chamber","40001757","CDM","275","RC","C1785","HCPCS","","","facility","both","","","","8125","8125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Patella Plate 2.7 3","40001758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3008.78","3008.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Patella Plate 2.7 3 Va","40001759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3309.8","3309.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.9Mm Guide Wire","40001760","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Basket Stone Retrv L90Cm","40001761","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","384.96","384.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Uret Cath 14Fr L15Cm","40001762","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","62.78","62.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Compression L150 Dia1.6 3","40001763","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","89.28","89.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp External Fixation Pin 6","40001764","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1485.86","1485.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40 D5 Tit Hindfoot","40001765","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90 D5 Tit Hindfoot","40001766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femoral 3-5","40001767","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W22Xl45 Standrd 2.4","40001768","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206.17","1206.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 D3 Thread 10","40001769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28 D3 Thread 11 Ti","40001770","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.7 Va Lckng Ant Patella Pl Ti","40001771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3008.78","3008.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L44 D3.5 Thred 11","40001772","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40 D4 Thread 10","40001773","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28 D4 Thread 7","40001774","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24 D3.5 Thread 6","40001775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L38 D3 Thread 15","40001776","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Patellar D35 Thk 9","40001777","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","914.89","914.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001778","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.5Mm Calibrated","40001779","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","175.1","175.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14 D5 Ster T25","40001780","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","585.5","585.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16 D5 Steril T25","40001781","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","620.63","620.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking For Med 5 34 25","40001782","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","809.68","809.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L170Mm Dia2.8Mm Cali","40001783","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","285.24","285.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 D2 Thread 8M","40001784","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Dia2Mm Long T","40001785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","773.7","773.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L93 4 Hole Left Md","40001786","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2034.01","2034.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10 D2.4 Unic","40001787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Buttress L20Mm Dia1.8Mm Di","40001788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 D3.5 Sm Gold","40001789","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X38Mm Compr Cann","40001790","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L60 Dia3.5 Cerv Tit","40001791","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","867.45","867.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L12 Od3.5 Polyaxi","40001792","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","604.97","604.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Size F D44 G7","40001793","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1822.28","1822.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Sz F Od44 28","40001794","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem D11 Dista","40001795","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1965.27","1965.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Spinal Posterior Cervic","40001796","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","225","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal Cervical Cavux Cag","40001797","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral L121 D11 13 Hip M","40001798","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neck Femoral Size Bb Hip Antev","40001799","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","959","959","","","","","","","","","","","","","Gross Charge Type: Standard"
"G7 Osseoti 4 Hole Shell 56Mm F","40001800","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4027.8","4027.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral L132 D16.25 132 C","40001801","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ifuse 7.0X40Mm","40001802","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L313 12 Hole Ster P","40001803","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2397.38","2397.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L320Mm Dia","40001804","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2986.5","2986.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surgical D16 Nonsterile","40001805","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1949.24","1949.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L5Mm Dia2.4Mm Titan","40001806","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","684.28","684.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W25.5Xl110 Ex 7X7","40001807","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2110.77","2110.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Size Cs2 Left Later","40001808","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1747.23","1747.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 6 L111 35 41","40001809","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4061.43","4061.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interference L25 Di9 Ant","40001810","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L300 D7.3 Quick Coup","40001811","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","626.3","626.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Size C Id28 6","40001812","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","2027.28","2027.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Dia28Mm +0Mm Offs","40001813","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2128.65","2128.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L29 Dia7 135","40001814","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","994.5","994.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 7Fr L65 Dlat 83","40001815","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 135 120 6","40001816","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 3 Rt Un","40001817","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2671.5","2671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tibial Size D Rt Prs","40001818","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size D T11 R","40001819","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X60 Cortical Hex","40001820","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.85","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X20 Cortical Hx","40001821","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.75","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X36 Cortical Hex","40001822","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.75","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X50 Cortical Hx","40001823","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.75","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30 D2.5 Thread 12","40001824","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L142.5 Thk2.5 12 H","40001825","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","891.68","891.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L90.5 Thk3.2 6H","40001826","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1144.8","1144.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28 D2.5 Thr 11","40001827","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 Di2.5 Thr 10","40001828","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22 Dia2 Long T 9","40001829","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 D3.5 Thread 9","40001830","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Temporary Fxtion L27 3.5","40001831","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.19","307.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L48Mm Dia3.5Mm Stan","40001832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","478.59","478.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14 Di3.5 Cort Can","40001833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16 Di3.5 Cort Ss","40001834","CDM","278","RC","","","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L12Mm Dia3.5Mm Ca","40001835","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1064.48","1064.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L34 Od3.5 Tit Can","40001836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1064.48","1064.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L180 Dia4.5 Add Std","40001837","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","219","219","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 7 L130Mm Od1","40001838","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2486.35","2486.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L80 Di8 135","40001839","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","994.5","994.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L184 13 Hole St 3.5","40001840","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.7","2076.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L79 2 Hole Poster 3","40001841","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1270.03","1270.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L147 8 Hole Rt 3.5","40001842","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2415","2415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 150 100 6","40001843","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 180Cm .035In","40001844","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","138.46","138.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fixation L200 Dia5 Thr 60","40001845","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","181.5","181.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gd 65Cm 6.5Fr Destino","40001846","CDM","272","RC","C1766","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patella Plate Bending Instr St","40001847","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1172.33","1172.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 4 L103Mm 12/14","40001848","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3241.88","3241.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 3 Plus","40001849","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","10968.56","10968.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplast L150 80 4","40001850","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od36 +2.5 Offset","40001851","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2148.92","2148.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Esph 23Mm 18.5Fr 10Cm 78","40001852","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2986.09","2986.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Fix Otsc","40001853","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","938.93","938.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip 235Cm Intnl Rsl Scrlk","40001854","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","255.02","255.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligator Endoscopic 6 Shooter S","40001855","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","895.44","895.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Flt Fibertak Fbrwr","40001856","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","823.62","823.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin External Fixation L180 D5","40001857","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","192","192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem L135 Di10 Fml","40001858","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2977.7","2977.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Femoral Size 3 Thk5 Pr","40001859","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1898.82","1898.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Femoral Size 3 Thk5 Pa","40001860","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1898.82","1898.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femoral 3-5","40001861","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Osteotome W8 Stainless S","40001862","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","182","182","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acetabular Size D Dia36","40001863","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2027.28","2027.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Sur L750Mm Dia1.7Mm Ss","40001864","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1258.2","1258.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 2.7 Shaft Cs3","40001865","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1667.54","1667.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 5 R","40001866","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L360Mm Dia","40001867","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L40 D3.5 Cerv Latx","40001868","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","745.14","745.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gw Vasc Std .035In 180Cm 3Cm","40001869","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","111.32","111.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 4.75Mm Swivelock C","40001870","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drn Clr 20In 20Fr Strg","40001871","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","211.26","211.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Surgical Reusable","40001872","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","359.83","359.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glenoid Sz 3 W 4","40001873","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1402.54","1402.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od32 +5 Offset","40001874","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1295.06","1295.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L108 Long 4 Hole 5","40001875","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L46 D3.5 Thread 12","40001876","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia3.5Mm Shor","40001877","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40 Di3 Long T 16","40001878","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M L82 2 Hole Nnst R","40001879","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inari Flowtriever Price Per Pr","40001880","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","15750","15750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ring Annuloplasty 30Mm Mitral","40001881","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4055.62","4055.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es 24Fr Lng Ovl Bttn","40001882","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","880.88","880.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es 24Fr 12Deg Lng M","40001883","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","847.27","847.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Endoscp L4Mm Dia13.4Mm Dst","40001884","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","63.3","63.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fixation L20 Dia2.5 V","40001886","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fixation L22 Dia2.5 V","40001887","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fixation L20 D2.5 Vr","40001888","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L80 Od5.4 Poster","40001889","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L85Mm Od5.4 Posteri","40001890","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 5Cc Calc","40001891","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1704.3","1704.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrd Es W1.5Cm D1.5Cm Shft","40001893","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","61.06","61.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passing Elevator Accessory Too","40001894","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L65 Dia5.4 Preb","40001895","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L46Mm 7 H Dst Uln Ss","40001896","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.84","1007.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 24Mm Ss 2.5Mm","40001897","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn 3.5Mm 6Mm 65Mm Dcp Lc","40001898","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.16","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn 3.5Mm 6Mm 70Mm Lc Dcp","40001899","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.23","48.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 75Mm Ss","40001900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.12","48.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 80Mm Cort St Sm","40001901","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.57","47.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn 3.5Mm 6Mm 85Mm Dcp Lc","40001902","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.77","47.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bn 3.5Mm 90Mm Cort St Sm","40001903","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt 137X11X3.4Mmss 3.5Mm 10 H","40001904","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","693.24","693.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Aln Srg Disp Lf Strl","40001905","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","640.5","640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrlzr Stm 11Mm Vrsy Hip Dist","40001906","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 13Mm Vrsy Hip","40001907","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","171.25","171.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 6.5Mm 25Mm Cmprh Ti","40001908","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","155.22","155.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.75Mm 25Mm Cmprh Ti","40001909","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","152.51","152.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.75Mm 20Mm Cmprh Ti","40001910","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.09","154.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bn Plc Lv 40Gm Brd","40001911","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","166.3","166.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 10Mm Ti Cort Ns","40001912","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Ti Cort Ns","40001913","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2.5Mm 18Mm Ft Lck Scr","40001914","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2.5Mm 20Mm Ft Ft Lck","40001915","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2.5Mm 22Mm Ft Lck Scr","40001916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agiliti Fbr Su 940Um","40001917","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","875.98","875.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.5Mm 25Mm Persona Kn","40001918","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","306.17","306.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Hd Ti Std Tpr Cmprh","40001919","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","586.44","586.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fx 2.5In 1/8In Stnm Ss","40001920","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","485.98","485.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2.5Mm 22Mm Ft Lck Scr","40001921","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","238","238","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor 16Mm 3.5Mm Gftmstr Rx","40001922","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3143.44","3143.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp <5 Yrs","40001923","CDM","370","RC","99151","HCPCS","","","facility","both","","","","528","528","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","40001924","CDM","370","RC","99152","HCPCS","","","facility","both","","","","479","479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea 15M","40001925","CDM","370","RC","99153","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp <5 Yrs","40001926","CDM","370","RC","99155","HCPCS","","","facility","both","","","","565","565","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp 5/>Yrs","40001927","CDM","370","RC","99156","HCPCS","","","facility","both","","","","524","524","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Ea","40001928","CDM","370","RC","99157","HCPCS","","","facility","both","","","","263","263","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L29 D6-8 1235","40001929","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4411.31","4411.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 6Fr L70 Dia2.2","40001930","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Lithotripsy L110 60 7","40001931","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","3609.38","3609.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovascular L10 Dista","40001932","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6302.37","6302.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femoral 6-9","40001933","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32Mm Dia3Mm Thread","40001934","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Dia3 Thread 14","40001935","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L320 9 Gr","40001936","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1657.36","1657.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Catheter L100Cm Od4Fr Guid","40001937","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L160Mm Dia","40001938","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1910.02","1910.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M 5Deg Right Mtp Fu","40001939","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3493.88","3493.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L97 12 Hole Bilat S","40001940","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","799.32","799.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L50 Dia2.7 H 5","40001941","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L55 Dia2.7 H 5","40001942","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 0Mm 12/14 Tpr 28Mm","40001943","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 125Mm 12Mm Prm Vrsy","40001944","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3883.95","3883.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 45Mm Mlplr Hip Mtl","40001945","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 46Mm Lgc Mlplr Hip","40001946","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 49Mm Lgc Mlplr Hip","40001947","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 9Mm Vrsy Hip","40001948","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","304.5","304.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +10.5Mm 12/14 Tpr 28","40001949","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Bp 50Mm 51Mm 28Mm Vrsy","40001950","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 52Mm Lgc Mlplr Hip","40001951","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 130Mm 13Mm Prm Cmnt","40001952","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2568.75","2568.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 140Mm 15Mm Prm Cmnt","40001953","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2568.75","2568.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 7 Nar Kn Lt Post","40001954","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 7 Nar Kn Rt Post","40001955","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 9 Std Kn Lt Post","40001956","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Std Kn Lt","40001957","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Std Kn Lt","40001958","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3158.4","3158.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona 4-11","40001959","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 10-12 Gh 10Mm Kn","40001960","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona 6-9","40001961","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona 3-11","40001962","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2111.36","2111.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz C 5Deg L Tib","40001963","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1269.99","1269.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz D 5Deg R Tib","40001964","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1264.44","1264.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona 5D E Kn","40001965","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1233","1233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz F 5Deg L Tib","40001966","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1251.49","1251.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz G 5Deg L Tib","40001967","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1269.99","1269.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 32Mm Persona","40001968","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1043.48","1043.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 35Mm Persona","40001969","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1043.41","1043.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 38Mm Persona","40001970","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1049.26","1049.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 41Mm Persona","40001971","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1042.91","1042.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40001972","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio .035In Pgtl Crv 5Fr","40001973","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","354.66","354.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio .035In Pgtl Flsh","40001974","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","354.66","354.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio Ang 5Fr .047In 100","40001975","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","132.33","132.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr L65Cm Gwire","40001976","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","131.7","131.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angiography 5 65 035","40001977","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","62.5","62.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blndil 10Mm 135Cm 20","40001978","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","508.31","508.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blndil 32Mm 120Cm Pu","40001979","CDM","278","RC","C2628","HCPCS","","","facility","both","","","","112.35","112.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Sprt 150Cm 3.1Fr","40001980","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","371.74","371.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Clsr 6Fr Prgld Prcls","40001981","CDM","278","RC","C1760","HCPCS","","","facility","both","","","","479.82","479.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Encr 20Cc Fngr Ltch","40001982","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","85.03","85.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Trq Gldcath Acpt","40001983","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","19.35","19.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular 260 035 15","40001984","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","300.5","300.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular 260 035 3 N","40001985","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","133","133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular 260 035 4.5","40001986","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","78.18","78.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular 300 Tip 014","40001987","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","325.8","325.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Shth 8Fr 2.5Cm 25Cm","40001988","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","61.75","61.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 10Cm 5Fr Pncl","40001989","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","32.61","32.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 10Cm 8Fr Pncl","40001990","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","38.96","38.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 33Cm 4.7Mm 12Fr","40001991","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","851.76","851.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro 10Cm 5Fr 21Ga Mak","40001992","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","42.6","42.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gd 65Cm 6Fr .109In .087","40001993","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","232","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio .035In Om Flsh Crv","40001994","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","346.14","346.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 135 120 6","40001995","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Med 16Mm Peek-Optm Lck","40001996","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Nar Kn Lt Post","40001997","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-12 Gh 11Mm Kn Rt","40001998","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz D 5Deg L Tib","40001999","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1250.41","1250.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona 5D H Kn","40002000","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1306.98","1306.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 29Mm Persona","40002001","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1052.16","1052.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 4 Kn Lt Mdl Prt","40002002","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3122.98","3122.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tibial Persona E Kne","40002003","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bear Tib Sz E Thk9Mm L Med","40002004","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 5-6 E-F 10Mm Kn Fx","40002005","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1486.69","1486.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 5 Nar Kn Rt Post","40002006","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Nar Kn Lt Post","40002007","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Nar Kn Rt","40002008","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3269.44","3269.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Std Kn Rt Post","40002009","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 7 Std Kn Rt Post","40002010","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Std Kn Lt Post","40002011","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3084.38","3084.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Std Kn Lt","40002012","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4946.17","4946.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 12 Std Kn Lt","40002013","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.81","4862.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 3-11","40002014","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1960.22","1960.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-12 Gh 10Mm Kn Lt","40002015","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2111.36","2111.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 6-9","40002016","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 325Cc 11.4 4","40002017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1756.8","1756.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L340 D9","40002018","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","998.4","998.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical, Multiple Post Collar","40002020","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","905.1","905.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia6Mm For Prophecy","40002021","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4 Antirotation Nt","40002022","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","3000.38","3000.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Tibial Dia16 Bilateral P","40002024","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1667.92","1667.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Tibial Dia16 Bilateral","40002025","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1562.4","1562.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Tibial Size 4 Standard Ri","40002026","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3671.06","3671.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inbone Everlast Sz 4 9Mm","40002027","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","7544.25","7544.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22 Cortical Hex","40002028","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.85","67.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Anterior Lordotic Cervical","40002029","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X40 Cortical H","40002030","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","79.24","79.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X46 Cortical Hx","40002031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.75","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X80 Cortical","40002032","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.75","74.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14Xh7Xl12 7 Deg","40002033","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L30 Anterior Ce 2","40002034","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1752.98","1752.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surgical L12 Od4 Ant Cer","40002035","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Vent Id1.27Mm 2.75Ifd Gry","40002036","CDM","278","RC","L8613","HCPCS","","","facility","both","","","","78.65","78.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload Stpl M 45Mm Crv Tip 2.0","40002037","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","414.91","414.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spinal L 30X39Mm 5Deg","40002038","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7016.08","7016.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Surgical Laser Hlm 2100","40002039","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","795.38","795.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L98 Thk3.4 7 Hole S","40002040","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.34","581.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L168 Thk3.7 8 Hl Ss","40002041","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3702.56","3702.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L155 Dia6.5 Thr 16","40002042","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L180 Dia6.5 Th 16 S","40002043","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Thk0.5 Long Roi-A","40002044","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L75 Short 3 Hole Ns","40002045","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.75","1647.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L400 D9","40002046","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1657.36","1657.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L184 10 Hole Ns 2.7","40002047","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1672.51","1672.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L161 8 Hole Ns 3.5","40002048","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1863.25","1863.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50 Dia6 Thor Tit","40002049","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1192.5","1192.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L55 Dia5.5 Titanium","40002050","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","514.5","514.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25 Dia5.5 Tit","40002051","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal H9 22X9 4Deg Tit","40002052","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4331.25","4331.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal Sm H6 8Deg Titaniu","40002053","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1890","1890","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal Sm H7 8Deg Tit Fus","40002054","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1890","1890","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L30 Anterior Bil","40002055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14 Dia4 Ant Tit","40002056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L12 Anterior Bila","40002057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.75","1338.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L36 Dia5 Locking Md","40002058","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","808.09","808.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 5Fr L70 035 Dl","40002059","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Halo One 5F Guiding Sheath Dia","40002060","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Halo One 5F Guiding Sheath D10","40002061","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L46 Dia2.7 Tit T8","40002062","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.67","237.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 Dia2.7 Mt T8","40002063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.86","107.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L85 Dia5 3.5 Cannul","40002064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472","472","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Alg W3 1/2X10In Tan","40002065","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","72.45","72.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Wnd 2.5Oz Hydrphlc Zn","40002066","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","24.92","24.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 8Mm Persona Vivacit-E","40002067","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 10Mm Persona Vivacit-E","40002068","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 3-5","40002069","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 6-9","40002070","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 6-9 Ef 12Mm Kn Rt","40002071","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3460.08","3460.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 10-11 Ef 12Mm Kn","40002072","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002073","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1233","1233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona 5D E Kn","40002074","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1265.37","1265.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 5 Kn Lt Mdl Prt","40002075","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2756.25","2756.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002076","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 6-9 Cd 10Mm Kn Lt","40002077","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 6-9 Cd 12Mm Kn Lt","40002078","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona","40002079","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz G 5Deg R Tib","40002080","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1242.25","1242.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 4 Kn Rt Mdl Prt","40002081","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3084.38","3084.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona F Kn Rt","40002082","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1669.5","1669.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002083","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5617.5","5617.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 265Mm 16Mm Wgnr Sl Rv","40002084","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","6097.68","6097.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002085","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3018.75","3018.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002086","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3018.75","3018.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","567","567","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002091","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Rt","40002092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Actb Kk 56Mm 32Mm Lngvt","40002093","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4861.56","4861.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +7Mm 12/14 Tpr 32Mm","40002094","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","926.25","926.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 5 Nar Kn Lt Post","40002095","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Nar Kn Rt Post","40002096","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Nar Kn Lt","40002097","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Std Kn Rt Post","40002098","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3187.8","3187.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 11 Std Kn Lt","40002099","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 9 Nar Kn Lt","40002100","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.81","4862.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 5 Std Kn Lt","40002101","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3130.64","3130.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Std Kn Rt","40002102","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3213","3213","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 3-11 Ef 11Mm Kn Lt","40002103","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 14Mm Persona 6-9","40002104","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona","40002105","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.38","2643.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 14Mm Persona","40002106","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2493.75","2493.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona","40002107","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.38","2643.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona 3-5","40002108","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3460.08","3460.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 14Mm Persona 6-9","40002109","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 10-11 E-F 10Mm Kn","40002110","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 7-12","40002111","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 16Mm Persona 6-9","40002112","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2493.75","2493.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem Sz F 5Deg R Tib","40002113","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1276.16","1276.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Cbl Blu 2.5Mm Fem Ti Al","40002114","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1233","1233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum 21Mm 57Mm 50Mm Shldr","40002115","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1306.98","1306.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 55Mm 15Mm Cmprh Por","40002116","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1233","1233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glnd Med 4Mm Bs Mdlr","40002117","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2415","2415","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bn Calcigen 25Ml Ptty","40002118","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3097.5","3097.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 79/83Mmx10Mm Mxm Arcm","40002119","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1260","1260","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Sft Tis Denovo Crtlg","40002120","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","6129.38","6129.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Std Kn Rt","40002121","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 12 Std Kn Rt","40002122","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 4 Std Kn Rt","40002123","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 11 Std R Cr Cocr","40002124","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4862.81","4862.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 6-9 Ef 12Mm Kn Lt","40002125","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2493.75","2493.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bear Tib Sz F Thk9Mm L Med","40002126","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 3-9","40002127","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.38","2643.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona 3-5","40002128","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.38","2643.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona 6-9","40002129","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2643.38","2643.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 6-9 Ef 11Mm Kn Rt","40002130","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona","40002131","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2493.75","2493.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 9Mm Persona Vivacit-E","40002132","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona F Kn Lt","40002133","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Kn Lt Mdl Prt","40002134","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2756.25","2756.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glnd Mdlr Hbrd Post","40002135","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona E Kn Rt","40002136","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 12Mm Persona Vivacit-E","40002137","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 11Mm Persona Vivacit-E","40002138","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 3 Kn Lt Mdl Prt","40002139","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3084.38","3084.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gw Vasc 500Cm .035In Sstf Tpr","40002140","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","232.4","232.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Asp 8- Cm 22Ga 1.83Mm","40002141","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","468.25","468.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gw Escp .035In 260Cm Radopq","40002142","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","323.37","323.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Duodenoscope Mod D For Ctrl","40002143","CDM","278","RC","C1748","HCPCS","","","facility","both","","","","5020.31","5020.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Bx 19Ga 1.14Mm Acquire","40002144","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","909.57","909.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Bx 286Cm 1.2Mm Spybit","40002145","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002146","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","210.12","210.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adhesive Skncls 2 Octyl","40002147","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","128.5","128.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lg Chevron Hrt Intl Hrzn","40002148","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7.23","7.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med Chevron Intl Weck","40002149","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2.66","2.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Sm Chevron Intl Weck","40002150","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","12.99","12.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Clsr 6Fr Strcls Se Vasc","40002151","CDM","278","RC","C1760","HCPCS","","","facility","both","","","","490.6","490.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"'8Mmx5Cm Via Vasc 120Cm Cath","40002152","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4759.32","4759.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 29Mm 8Mm 16Sq Mm","40002153","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4411.31","4411.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt 15Cm 31Mm Gore Tag","40002154","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","25476.94","25476.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Embl Navalign Dlv","40002155","CDM","278","RC","C1880","HCPCS","","","facility","both","","","","2092.5","2092.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Cath T-B Pls Acpt 9Fr","40002156","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","50","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Intbt 600Mm 15Fr 2.5-11","40002157","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","137.18","137.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Glnd Cmprh Med Shldr","40002158","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3445.31","3445.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Actb 52Mm Hip Lmt Hl","40002159","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4027.8","4027.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Actb G7 E 42Mm Cocr Hip","40002160","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Hip 42Mm 28Mm E","40002161","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1941.97","1941.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 114Mm 7.5Mm Zm Ml Tpr","40002162","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neck Fem Zm Ml Kinectiv R1","40002163","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","959","959","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +0Mm 12/14 Med 28Mm","40002164","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1618.31","1618.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tib Grn Strp 74X46Mm","40002165","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2760.94","2760.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona 3-9","40002166","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Block Aug Nxgn 5 Full 10Mm Kn","40002167","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2036.1","2036.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Xtn 100Mm 11Mm Nxgn Ofst","40002168","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2190.6","2190.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 9 Nar Kn Lt Post","40002169","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 9 Nar Kn Rt Post","40002170","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Nar Kn Lt","40002171","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 9 Std Kn Lt","40002172","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3244.5","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 11Mm Persona 6-9","40002173","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Joint Device (Implantable)","40002174","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum 21Mm 43Mm 42Mm Shldr","40002175","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2256","2256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 55Mm 10Mm Cmprh Por","40002176","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.9Mm 2 Juggerknot","40002177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","976","976","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Orth Gd Lt Cmprh","40002178","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1795.5","1795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Orth Aug Gd Lt","40002179","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1795.5","1795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona 6-9","40002180","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2177.24","2177.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glnd 2 4 Pg Mdlr Aln","40002181","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1486.69","1486.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glnd Post Mdlr Aln","40002182","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","762.41","762.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Aln Srg Disp Lf Strl","40002183","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","640.5","640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum 24Mm 52Mm 50Mm Shldr","40002184","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2256","2256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 83Mm 11Mm Cmprh Por","40002185","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 122Mm 16Mm Cmprh Por","40002186","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L26 D4 Oc Upper","40002187","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1885.28","1885.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25 Dia5.5 Oc Up","40002188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1885.28","1885.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25 Dia5.5 Oc Up","40002189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","269.32","269.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal M Occipitocer","40002190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1254","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovascular Stent 14 36","40002191","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16695","16695","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Kyphoplasty Size 2 Bal 10","40002192","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","5418.92","5418.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding L70 Id2.5 035","40002193","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L420 D9 Gr","40002194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1657.36","1657.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L58 D4 Ss Cann 1/2","40002195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L55Mm +20Deg 3X5 Ho","40002196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","918.36","918.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L55 -20Deg 3X5 H Ns","40002197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","918.36","918.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L48 D2.7 Cort Ss T8","40002198","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L46 Dia2.7 Cort Ss","40002199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W22Xl54 Stnd 6X3","40002200","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1198.65","1198.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L440 D9 Ti","40002201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1657.36","1657.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L38 D4 Ss Cann Shrt","40002202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Sm 8 Hole Left 2.7","40002203","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4013.63","4013.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500 Di5.5 Thora","40002204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1746.13","1746.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 D5.5 Post Tho","40002205","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 D5.5 Post Tho","40002206","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32 Dia2.7 Tit Slf","40002207","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.67","237.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L238Mm Blade W5.8Xl","40002208","CDM","270","RC","C1713","HCPCS","","","facility","both","","","","1120.29","1120.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Medl 6 134","40002209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Extend 2 85","40002210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.75","1647.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L270Mm Blade W5.8","40002211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1120.29","1120.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Ulna Extra-Artic 10","40002212","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1672.51","1672.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Lat 2 82 2","40002213","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L302Mm Blade 5.8Xl3","40002214","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1153.8","1153.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrograde Femoral Nail 11 360","40002215","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","4732.88","4732.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L52 Dia5 Locking Me","40002216","CDM","270","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw For Medullary Nail 5 Lck","40002217","CDM","270","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 120 Dia4.2 Calib","40002218","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","812.85","812.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L238Mm Blade W5.8Xl","40002219","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw For Medullary Nail 5 82","40002220","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1019.29","1019.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw For Medullary Nail 5 32","40002221","CDM","270","RC","C1713","HCPCS","","","facility","both","","","","799.09","799.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw For Medullary Nail 5 68","40002222","CDM","270","RC","C1713","HCPCS","","","facility","both","","","","841.43","841.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dural Adult W4Xl5In Bios","40002223","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2105.71","2105.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 9 Hole Broad 170 Ss","40002224","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","980.42","980.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L174Mm Blade W5.8 3","40002225","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.45","896.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tibial Size G Thk9Mm R","40002226","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dilatation 7.5Fr L180","40002227","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia2.7 Cort Ss","40002228","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32 D2.7 Cort Ss Lw","40002229","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 D2.7 Foot Ss","40002230","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.7Mm Distal Tibi","40002231","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","175.1","175.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Perf L2.3In Tip L2Mm","40002232","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","11.91","11.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Perf 9Fr L5.5In Aort","40002233","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","24.44","24.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Pos 7 127 2","40002234","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.75","1647.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Ulna Extra-Ar 6 131","40002235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1672.51","1672.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tibial Size D Thk9 Lf","40002236","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw External Fixation L150 5","40002237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.9","235.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L248 Dia2.8 Quick","40002238","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","215.1","215.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tibial Size D Lt Md","40002239","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Ltrl 7 147","40002240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spinal Sm 26X31 11D S","40002241","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6618.94","6618.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spinal Sm 26X31 5D Lu","40002242","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6618.94","6618.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L16 Od2.5 Ant Cerv","40002243","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchr Sut 4.5Mm Peek","40002244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","876","876","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Glnd Cmprh 25Mm Mn","40002245","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2703.75","2703.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Hum 36Mm Cmprh Std","40002246","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1544.29","1544.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Orth Gd Rt Cmprh","40002247","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1795.5","1795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Orth Aug Gd Rt","40002248","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1903.23","1903.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Ef","40002249","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona","40002250","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Std Kn Lt","40002251","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3225.6","3225.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Gh Fem 7-12","40002252","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1089.15","1089.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 12 Std Kn Lt","40002253","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 12Mm Persona","40002254","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona 5D H Kn","40002255","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1269.99","1269.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia3.5Mm Cort","40002256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W31.5Xl62.7Mm Std L","40002257","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.13","1504.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2Mm 26Mm Smth Lck Dvr","40002258","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Fx 2Mm 30Mm Smth Lck Dvr","40002259","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 122Mm 11Mm Cmprh Por","40002260","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4368.01","4368.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Hum 36Mm Cmprh +3Mm","40002261","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1544.29","1544.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 7 Std Kn Lt Post","40002262","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona G Kn Lt","40002263","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 10Mm Persona Vivacit-E","40002264","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femoral 10-1","40002265","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Humeral L122 Dia12 Standa","40002266","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4350.94","4350.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Orth Cocr 1.8Mm 635Cm","40002267","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1110","1110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Humeral H18 Od53 Id46 Cob","40002268","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2391.36","2391.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 9 Stand","40002269","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tibial Size A Left M","40002270","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tibial Sm Thk3Mm Left","40002271","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Sm Partial K","40002272","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size E Thk8","40002273","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 59.5X24.4Mm Ti 4 Hl","40002274","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.13","1504.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W24.4Xl51.3Mm Sht","40002275","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.13","1504.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bil Oasis Leung 10Frx9Cm","40002276","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Size 6 Rt Kn","40002277","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2671.5","2671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tibial Size G Rt","40002278","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotid L40 D8 Bmr","40002279","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3543.75","3543.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotid L40 D10 57","40002280","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3756.38","3756.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular D0.014 Ss H","40002281","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","1534.73","1534.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Neuroprotection Tran An","40002282","CDM","270","RC","C1894","HCPCS","","","facility","both","","","","4771.2","4771.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grasper Endoscp L200Cm Shth","40002283","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","283.5","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Plsrb 4-0 C-13 30In Brd","40002284","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","283.5","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 122Mm 11Mm Cmprh Por","40002285","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3379.69","3379.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella 13Frx13 Introducer","40002286","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella 14Fr Introducer","40002287","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gd Pin Orth Persona Fem Tib","40002288","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","283.5","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"18Fr 14Fr Pu Loprfl Syr","40002289","CDM","270","RC","C1894","HCPCS","","","facility","both","","","","449.69","449.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Laparoscopic L44Cm Dia5","40002290","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","4937.21","4937.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Cor Stnt 16Mm 2.8Mm","40002291","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3143.44","3143.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Cor Stnt 19Mm 2.8Mm","40002292","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3143.44","3143.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor 16Mm 4Mm 6Fr Gftmstr","40002293","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3143.44","3143.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Cor Stnt 19Mm 4Mm","40002294","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3143.44","3143.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 14Mm Tryptik 2","40002295","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504","504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 20Mm 1 Lvl Tryptik 2 Bn","40002296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1209","1209","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 190Cm .018In","40002297","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 300Cm .018In","40002298","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"22Fr 18Fr Pu Loprfl Syr","40002299","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","449.69","449.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"24Fr 20Fr Pu Loprfl Syr","40002300","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","449.69","449.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Shth 8Fr 13Cm 3W","40002301","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","89.28","89.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advancer Bur Rtbltr Rtlnk","40002302","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Athrcm 135Cm 1.25Mm","40002303","CDM","278","RC","C1724","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Athrctmy L135Cm","40002304","CDM","278","RC","C1724","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Athrcm 135Cm 1.75M","40002305","CDM","278","RC","C1724","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Athrcm 135Cm 2.5Mm Rtbltr","40002306","CDM","278","RC","C1724","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing 8Mm Persona Vivacit-E","40002307","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 182Cm .014In","40002308","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","170","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snr 120Cm 15Mm 6Fr Agn","40002309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","640.5","640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cv 9.3Fr 38Cm 3 Infs Lum","40002310","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","1138.58","1138.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vlv Hmsts .115In Duostat Rot","40002311","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","57.5","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 45Cm 9.3Fr Quattro","40002312","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","1448.36","1448.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 145Cm .014In","40002313","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","183.74","183.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blndil 2Mm 8Mm Cor Rx","40002314","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trchbr 6Mm 7Fr 38Mm 120","40002315","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3379.69","3379.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trchbr 9Mm 7Fr 38Mm 120","40002316","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3379.69","3379.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligator 9.5-11.5Mm 6Shtr Sa","40002317","CDM","270","RC","","","","","facility","both","","","","497.2","497.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Diagnostic L100 Od5","40002318","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","30","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angiographic 5Fr 0.45","40002319","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","30","30","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pncr 5Fr 3Cm Cntr Push","40002320","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","148.4","148.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc 45Cm 4-7Mm Gore","40002321","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2248.5","2248.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blndil Mic 1.2Mm 150","40002322","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","866.25","866.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Dia6.5 Anci Tri","40002323","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","137.56","137.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Prss Mon W/ 3Fr 24In L Atr","40002324","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","94.1","94.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 48Mm Ss Cort St","40002325","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.3","67.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Intraaortic Blln 7.5Fr","40002326","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1485.86","1485.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Access Uropass L38 Cm O","40002327","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","356.52","356.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Escp Acc Bx Chnl Ns","40002328","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","11.24","11.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Cystometry Od10Fr Abd","40002329","CDM","278","RC","","","","","facility","both","","","","112.55","112.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Irr Otclr Ns Lf Disp","40002330","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","5.08","5.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Prln 3-0 Sh 36In 2 Arm Mfl","40002331","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","50.5","50.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 12Mm Ortholoc","40002332","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","821.1","821.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 14Mm Ortholoc","40002333","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","821.1","821.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 16Mm Ortholoc","40002334","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","795.9","795.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L16Mm Dia2.7Mm Cort Ti","40002335","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 20Mm Ortholoc","40002336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 24Mm Ortholoc","40002337","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 30Mm Ortholoc","40002338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 30Mm Dart-Fire Ti","40002339","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","743.48","743.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 34Mm Dart-Fire Ti","40002340","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","743.48","743.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 36Mm Dart-Fire Ti","40002341","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","743.48","743.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 38Mm Dart-Fire Ti","40002342","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","765.74","765.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 36Mm Dart-Fire Ti","40002343","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","722.4","722.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12 Dia2.7 Cort 3Di","40002344","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18 Dia2.7 Tit Ff M","40002345","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aloka Alpha 6 Rob Drop In Prob","40002346","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","3024.62","3024.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hp Thulium 1000Um Fiber","40002347","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Sz 1 L96 Neck 34","40002348","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neck Femoral Size R2 Hip Antev","40002349","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","959","959","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral L124 D12.5 132","40002350","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acetabular Dia54Mm Sz 4","40002351","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4027.8","4027.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Sm L42 10Deg 6 H Lt","40002352","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3493.88","3493.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Morcellator Hysteroscopic 5 5C","40002353","CDM","270","RC","C1782","HCPCS","","","facility","both","","","","946","946","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus 75 2.7/3.5","40002354","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus 4 88 2.7/3","40002355","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Fmrl 8-11 14","40002356","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L80 Dia7.3 Thr 16 C","40002357","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90 D7.3 Thr 32 Can","40002358","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95 D7.3 Thr 32 C","40002359","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Orthopedic L L50 D1 Ally","40002360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2825.95","2825.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hip 12 Hole 206 5.8","40002361","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","884.49","884.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw External Fixation L175 5","40002362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.9","235.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Orthopedic Dia4.5Mm Tit Po","40002363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.54","278.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L31Mm 4 H Bilat Ti","40002364","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","401.16","401.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L38Mm 5 H Bilat Ti","40002365","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","401.16","401.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L59Mm 7 H Bilat Cndyl","40002366","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","983.3","983.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Hum Posterolateral Dst","40002367","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.27","1598.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Hum Ext Med Dst L 2 H","40002368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1647.75","1647.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Rad Dst Volar Two Clmn","40002369","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1467.68","1467.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L32Mm Dia2.7Mm Cort","40002370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L34Mm Dia2.7Mm Cort","40002371","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L32Mm Dia2.7Mm Hd","40002372","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","117.13","117.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L28Mm Dia2.4Mm","40002373","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia2.4Mm","40002374","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X7 H Bilat Ti Y Shp","40002375","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","758.46","758.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24 D2.4 Stan Cort","40002376","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","147.78","147.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 D2.4 Uncort Tit","40002377","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 D2.4 Uncort Tit","40002378","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14 D2 Std Cort Tit","40002379","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 Di2 Std Cort Ti","40002380","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22 Di2 Stand Tit","40002381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18 D2 Cort Tit","40002382","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 D2 Cort Tit St","40002383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 10 Hole 73 Tit Mdl","40002384","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","428.42","428.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3X7 Hole T-Plate 58","40002385","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","901.85","901.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Degree Lordotic Shell 15","40002386","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Dia5.5Mm Healicoil","40002387","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","781.2","781.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Bioinductive L Bov","40002388","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","5250","5250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Perf L2.3In Tip L3Mm","40002389","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","23.82","23.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Perf L2.3In Tip L4Mm","40002390","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","23.82","23.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovascular L80 D28","40002391","CDM","278","RC","C1784","HCPCS","","","facility","both","","","","3662.23","3662.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16 Od3.5 Polaxia","40002392","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1876.95","1876.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L235 10 12","40002393","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2390.75","2390.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L235 125 G","40002394","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2415.52","2415.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill","40002395","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","174.42","174.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surgical L14 Fixed Disp","40002396","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","880","880","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prebent Rod Cobalt Chromium","40002397","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit/Stryker J-Latc 2.4","40002398","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","163.14","163.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bngf 3Cc Aug Inj","40002399","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4937.3","4937.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum Posterolateral","40002400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1660.13","1660.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Humerus Mdl 2L 82","40002401","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1772.6","1772.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia3.5Mm Cort","40002402","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.12","90.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5 Hole Right Distal","40002403","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","975","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L14Mm Dia3.5Mm Cort","40002404","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","88.55","88.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Internal Delivery Sys235","40002405","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","617.33","617.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking For Mdl 5 62 25","40002406","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","841.43","841.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Femr Proximl 12 313","40002407","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2343.3","2343.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L55Mm D5.5 Shor Can","40002408","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L60 D5.5 Shor Cann","40002409","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L70 D5.5 Canc Cann","40002410","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Driver Surgical D5.5 Str Hex","40002411","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1069.5","1069.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 D3 Sm Brown Tit","40002412","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Bne Sub 2.5Cc Peptide En","40002413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","927","927","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant 7.0 Mm X 35 Mm","40002414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4869.38","4869.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Surgical Patient Sp Talu","40002415","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","3000.38","3000.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18 Di2.5 Shor Tit","40002416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20 D2.5 Thre 5 Sh","40002417","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30 Di4 Cancel Tit","40002418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 Hole 36 Tit 2.4","40002419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","687.31","687.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 12 Hole Adapt 88 2","40002420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","799.32","799.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Dia2.4Mm Stan","40002421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","147.78","147.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26 Di2.4 Stan Tit","40002422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","147.78","147.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 Di2.4 Stan Cran","40002423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.22","118.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation L150 Di2 15","40002424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.06","229.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Catheter Pump Left Ventric","40002425","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","31250","31250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tibial Size E Left F","40002426","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3668.18","3668.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem L135 D11 3 Off","40002427","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3740.1","3740.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hernia Midline W6.1Xl10","40002428","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2655.9","2655.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L10 Tit Post Cerv","40002429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","818.09","818.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L5 D2.6 Tit Sl Tp","40002430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","162.44","162.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L5.5 D1.9 Nonradiolu","40002431","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L7 Dia2.6 Tit Cnt","40002432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","162.44","162.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Embolization L30 Pking J","40002433","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1968.75","1968.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Embolization L45 Pkng J L","40002434","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1968.75","1968.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L12 D3.5 No1 Poly","40002435","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1502.55","1502.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spinal Tit Alloy Ply","40002436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","269.09","269.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spinal Od5.5 Pedicle","40002437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Bne Sub 5Cc Peptide Enh","40002438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3826.59","3826.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon Lft 4 116","40002439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1454.31","1454.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Radius Distal 6X5 2","40002440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1354.18","1354.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon Rt 4 116","40002441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1541.57","1541.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fibula Ltrl 3 79 Ss","40002442","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1075.47","1075.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 D5.5 Yw Ply C","40002443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1786.54","1786.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 D6.5 Gr Can P","40002444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1811.75","1811.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 D6.5 Gr Ply C","40002445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2021.25","2021.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Locking Sr25 Mome","40002446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","268.58","268.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500 D6 Light Blue","40002447","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","537.6","537.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 15X5 12 Tryp Tik","40002448","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4329.62","4329.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Cage","40002449","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4350.94","4350.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contour 2.5 Cc","40002450","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","1496.25","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 38Mm Dart-Fire","40002451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 0D Sm 42Mm Recon Loprfl","40002452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3703.51","3703.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 14Mm Ortholoc","40002453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 16Mm Ortholoc","40002454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Ortholoc","40002455","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","870.37","870.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 15X5Mm 12Mm Tryptk","40002456","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4344.38","4344.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Intvrtb 15X5Mm Mobi-C 15","40002457","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7229.25","7229.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac Jt L80Mm","40002458","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 26Mm Dart-Fire Ti","40002459","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","708.08","708.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5 18 Ortholoc","40002460","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5 14 Ortholoc 3D","40002461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","821.1","821.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Hum Tiss 2.5Sqcm Dehydr","40002462","CDM","278","RC","Q4186","HCPCS","","","facility","both","","","","1027.5","1027.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss 4Sqcm Dehydr","40002463","CDM","278","RC","Q4186","HCPCS","","","facility","both","","","","1551.38","1551.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Alg W4Xl5In Hydrfbr Rect","40002464","CDM","272","RC","A6197","HCPCS","","","facility","both","","","","21.96","21.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Sz 11 Std Lf","40002465","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3339","3339","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ureteral 5Fr L65 C1","40002466","CDM","278","RC","C1758","HCPCS","","","facility","both","","","","185.54","185.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L41 Thk1.9 Ant Ti","40002467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2671.88","2671.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Joint Device (Implantable)","40002468","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3268.12","3268.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plug Vascular 6Fr L12 D16 8Fr","40002469","CDM","278","RC","C1817","HCPCS","","","facility","both","","","","1248","1248","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Lord Full Machined","40002470","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1720.69","1720.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hum Comp Dia40Mm Thk+5Mm","40002471","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2363.25","2363.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchr Sut Dia2.9Mm No2","40002472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","913.5","913.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Bne L26Mm Dia2.7Mm Cort S","40002473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Rep Kntlss Lp W/ Dog Bne","40002474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2566.5","2566.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L Thk1.25 9 Hl Lft","40002475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2743.5","2743.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30 D3 Calcan Tit H","40002476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32 D3 Elbow Tit","40002477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 D3 Elbow T Hex","40002478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L36 D3 Foot Titan","40002479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L45 D3 Calcan Tit H","40002480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30 D3 Elbow Tit Fl","40002481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","508.2","508.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32 D3 Elbow T Hex","40002482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","508.2","508.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34 D3 Elbow Tit H","40002483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","508.2","508.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic L9.25 D0","40002484","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar L11.5Cm Dia18Mm","40002485","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6302.37","6302.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 5 L110Mm Dia8.9Mm","40002486","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2443.5","2443.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Fem Dia9Mm Univ Dst Hip","40002487","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","140","140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L330 D8 Bl","40002488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Narrw S R 21.6 48.9","40002489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.13","1504.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Intramedullary L1150Mm Dia","40002490","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","229.22","229.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Endopros L12Cm Aort","40002491","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","14555.63","14555.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blln Dil L17Mm Dia7Mm","40002492","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","1198.05","1198.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kt Infl 18In For Blln Snus Dil","40002493","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","350.86","350.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar L13.5Cm Dst Dia18Mm","40002494","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70 Xl25 Rc Tit Rf","40002495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.71","805.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Endopros L14Cm Dst","40002496","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6302.37","6302.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar Stnt L12Cm","40002497","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16695","16695","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia6.5Mm Post","40002498","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.05","1146.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L40Mm Dia6.5Mm Post","40002499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.05","1146.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","191","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia5.5Mm Post","40002501","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L80Mm Dia5.5Mm Post","40002502","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 11.2 Cannulated Larg","40002503","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2162.46","2162.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L40Mm Dia5.5Mm Post","40002504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L50Mm Dia6.5Mm Post","40002505","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.05","1146.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl W10Xh8Xl25Mm 10Deg","40002506","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3008.39","3008.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L45Mm Dia5.5Mm Post","40002507","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W17.5Xl32Mm","40002508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.19","1504.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L16Mm Dia4Mm Ant","40002509","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","334.26","334.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M Titanium Right Ca","40002510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2547.18","2547.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28 D3 Elbow Tit","40002511","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","190","190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28 D3 Calcan Tit H","40002512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L35 D5.5 Self Drl C","40002513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.5","877.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L D5.5 Long For Hdls","40002514","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","884.84","884.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Driver Surgical Tip D3 Long He","40002515","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","725.68","725.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Coronary L34 Id2.75 Cob","40002516","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L150 D14 9 90","40002517","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2593.75","2593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Peripheral L80 D16 90 9","40002518","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L44.5 D1.4 6 Stop J","40002519","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","548.1","548.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Sz 11 170 Od13.5","40002520","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3831.54","3831.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tibia Mdl Prx 6 119","40002521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1887.07","1887.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Fixation L160 D6 Spade S","40002522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","133.65","133.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Arthroscopic 4 D12 Dm","40002523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Anchor Curvd Disp Ft","40002524","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","434.07","434.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aloka Alpha 6 4 Way Lap Probe","40002525","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","3024.62","3024.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Dia36 +5 Offset","40002526","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2027.28","2027.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation L150 D1.6 20","40002527","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","94.64","94.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem -2.5Mm Ofst Tpr 36Mm","40002528","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1246.19","1246.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Graft Substitute 5 Cc","40002529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1677.38","1677.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L405 D10 U","40002530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peripheral Access Ndl 21 4","40002531","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Ultrasound Uronav Laser","40002532","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","645.56","645.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ultrasound Biopsy Single Needl","40002533","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","92.75","92.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X30Mm Locking Mdl","40002534","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","817.62","817.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer 14/7","40002535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","297.51","297.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrograde Femoral Nail 12 200","40002536","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5458.69","5458.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nut 14 Sterile","40002537","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","853.65","853.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer 17.5/11.8","40002538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","298.2","298.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L55 D3.5 Cerv Tit P","40002539","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12 Di2.5 Thre Cann","40002540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 1Cc Pept","40002541","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","924.92","924.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tibial Size Ef Thk15 L","40002542","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1898.82","1898.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33123500-01 3.5 Ti Rod 1","40002543","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33123500-02 3.5 Ti Rod 4","40002544","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33125512-01 5.5 Ti Rod 1","40002545","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33125512-02 5.5 Ti Rod 4","40002546","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33126012-01 6.0 Ti Rod 1","40002547","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33126012-02 6.0 Ti Rod 4","40002548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33136012-01 6.0 Ti Drod","40002549","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33143500-01 Dual 3.5/5.5","40002550","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33143600-01 Dual 3.5/6.0","40002551","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33145600-01 5.5/6.0 Ti 1","40002552","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33155522-01 Ti Perc 5.5","40002553","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33155522-02 Ti Perc 5.5","40002554","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33156022-01 Ti Perc 6.0","40002555","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33156022-02 Ti Perc 6.0","40002556","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33223500-01 3.5 Cc Rod 1","40002557","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33223500-02 3.5 Cc Rod 4","40002558","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L34 D3.5 No 1","40002559","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33225512-01 5.5 Cc Rod 1","40002560","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33225512-02 5.5 Cc Rod 4","40002561","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2170.35","2170.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33226012-01 6.0 Cc Rod 1","40002562","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33226012-02 6.0 Cc Rod 4","40002563","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33236012-01 6.0 Cc Drod","40002564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33243500-01 Dual 3.5/5.5","40002565","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33243600-01 Dual 3.5/6.0","40002566","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33245600-01 5.5/6.0 Cc 1","40002567","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33255522-01 Cc Perc 5.5","40002568","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33255522-02 Cc Perc 5.5","40002569","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33256022-01 Cc Perc 6.0","40002570","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unid B33256022-02 Cc Perc 6.0","40002571","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L40 D3.5 Tit Lordot","40002572","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L24 Di3.5 No1 Ply","40002574","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal D6 Offset Rod","40002575","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1693.13","1693.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Vbr H28-39 D13Green","40002576","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14463.44","14463.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Dia16 0Deg Ang Vb","40002577","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3189.38","3189.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500 D5.5 Yw Tt Str","40002578","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","540.75","540.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Neg Prss W5Xl8In","40002579","CDM","272","RC","A6207","HCPCS","","","facility","both","","","","88.2","88.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 5D Sm 42Mm Recon Loprfl","40002580","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3493.88","3493.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Alg W0.39Xl18In Hydrfbr","40002581","CDM","272","RC","A6199","HCPCS","","","facility","both","","","","18.6","18.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit Flexible 12 Mm Long","40002582","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2679.97","2679.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54 Xl25 Recess Rf","40002583","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.71","805.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrograde Femoral Nail 10 340","40002584","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5569.18","5569.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X72 Xl25 Rces Tit","40002585","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","841.43","841.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W10Xh12Xl25Mm 15","40002586","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3008.39","3008.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Spnl L50Mm Dia6.5Mm Cort","40002587","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1403.11","1403.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Spnl L45Mm Dia6.5Mm Cort","40002588","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl W16Xh5Mm D14Mm 7Deg","40002589","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl W16Xh6Mm D14Mm 7Deg","40002590","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Fast-Fix Flex","40002591","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","866.25","866.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Calcaneus Ant 56","40002592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1683.28","1683.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acessa Provu Dispsable Handpi","40002593","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","4331.25","4331.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif Acd Ec Ti 8","40002594","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5906.25","5906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif Ac Eh Ti 15","40002595","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5906.25","5906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 11Mm 8Deg Alif Ze","40002596","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 13Mm 15Deg Alif Z","40002597","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif Vb 5X25","40002598","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.85","500.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver Surg 3.5Mm 90Deg","40002599","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","125","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem -3.5Mm 12/14 Tpr 28Mm","40002600","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","898.8","898.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 130Mm 13Mm Prm Vrsy","40002601","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5442.94","5442.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 135Mm 14Mm Prm Vrsy","40002602","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5442.94","5442.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 115Mm 10Mm Prm Vrsy","40002603","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 125Mm 12Mm Prm Vrsy","40002604","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 130Mm 13Mm Prm Vrsy","40002605","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 43Mm Mlplr Hip Mtl","40002606","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 44Mm Mlplr Hip Mtl","40002607","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 48Mm Mlplr Hip Mtl","40002608","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 12Mm Vrsy Hip","40002609","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 14Mm Vrsy Hip","40002610","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 15Mm Vrsy Hip","40002611","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 42Mm Hip Unplr","40002612","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","780.15","780.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 45Mm Hip Unplr","40002613","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 47Mm Hip Unplr","40002614","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 48Mm Hip Unplr","40002615","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 49Mm Hip Unplr","40002616","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Hd Vrsy Lgc +10.5Mm","40002617","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 0Mm 12/14 Tpr 22Mm","40002618","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","674.1","674.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +3.5Mm 12/14 Tpr 28Mm","40002619","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","674.1","674.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 54Mm Hip Unplr","40002620","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 44Mm Hip Unplr","40002621","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tib 2Mm Nxgn Kn Prect","40002622","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2722.5","2722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 3-4 E-F 14Mm Kn Fx","40002623","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem G Kn Rt Cmnt Ng","40002624","CDM","278","RC","","","","","facility","both","","","","4222.97","4222.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tib 7Mm Nxgn Kn Prect","40002625","CDM","278","RC","","","","","facility","both","","","","2722.5","2722.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-10 G-H 10Mm Kn","40002626","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem F Kn Lt Cmnt Ng","40002627","CDM","278","RC","","","","","facility","both","","","","3378.38","3378.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tib 8Mm Nxgn Kn Prect","40002628","CDM","278","RC","","","","","facility","both","","","","81.25","81.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-10 G-H 12Mm Kn","40002629","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 41Mm Nxgn Prlng","40002630","CDM","278","RC","","","","","facility","both","","","","1221","1221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem G 76.5X70.4Mm Kn","40002631","CDM","278","RC","","","","","facility","both","","","","4526.16","4526.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-10 C-H Std 82X51","40002632","CDM","278","RC","","","","","facility","both","","","","1888.42","1888.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem G Kn Lt Cmnt Ng","40002633","CDM","278","RC","","","","","facility","both","","","","4222.97","4222.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 5-6 G-H 12Mm Kn Fx","40002634","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem E Kn Lt Ng","40002635","CDM","278","RC","","","","","facility","both","","","","4663.31","4663.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 3-4 E-F 10Mm Kn Fx","40002636","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem F Kn Rt Cmnt Ng","40002637","CDM","278","RC","","","","","facility","both","","","","4222.97","4222.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 5-6 G-H 14Mm Kn Fx","40002638","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 5-6 G-H 10Mm Kn Fx","40002639","CDM","278","RC","","","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem E Kn Lt Ng","40002640","CDM","278","RC","","","","","facility","both","","","","4222.97","4222.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr Std 10Mm 41Mm","40002641","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","904","904","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 7-10 G-H 12Mm Kn","40002642","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1775.81","1775.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem G 76.5X70.4Mm Kn","40002643","CDM","278","RC","","","","","facility","both","","","","4526.16","4526.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem F 72X65.4Mm Kn","40002644","CDM","278","RC","","","","","facility","both","","","","4526.16","4526.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem E Kn Rt Cmnt Ng","40002645","CDM","278","RC","","","","","facility","both","","","","4222.97","4222.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem E- Kn Lt Cmnt","40002646","CDM","278","RC","","","","","facility","both","","","","4966.5","4966.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 42Mm Mlplr Hip Mtl","40002647","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 47Mm Mlplr Hip Mtl","40002648","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 50Mm Mlplr Hip Mtl","40002649","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shl Bp 53Mm Mlplr Hip Mtl","40002650","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 54Mm Mlplr Hip Mtl","40002651","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 55Mm Mlplr Hip Mtl","40002652","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 43Mm Hip Unplr","40002653","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 46Mm Hip Unplr","40002654","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 51Mm Hip Unplr","40002655","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 52Mm Hip Unplr","40002656","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 53Mm Hip Unplr","40002657","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 55Mm Hip Unplr","40002658","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem -2Mm 12/14 Tpr 22Mm","40002659","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","898.8","898.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +3Mm 12/14 Tpr 22Mm","40002660","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","898.8","898.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +7Mm 12/14 Tpr 28Mm","40002661","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","898.8","898.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm 11Mm Prm Vrsy","40002662","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 240Mm 3.5Mm Std","40002663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.8","877.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 140Mm 15Mm Prm Vrsy","40002664","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 130Mm 13Mm Prm Vrsy","40002665","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm 17Mm Prm Vrsy","40002666","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5385.19","5385.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm 17Mm Prm Vrsy","40002667","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5442.94","5442.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 145Mm 16Mm Prm Cmnt","40002668","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2760","2760","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm 11Mm Cmnt Vrsy","40002669","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 125Mm 12Mm Cmnt Vrsy","40002670","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 135Mm 14Mm Cmnt Vrsy","40002671","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 145Mm 16Mm Cmnt Vrsy","40002672","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 135Mm 14Mm Prft Vrsy","40002673","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1618.31","1618.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Cbl 53X23Mm Cbl Rd Shrt","40002674","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2687.58","2687.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 8 Nar Kn Rt Cr","40002675","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3244.5","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm 6-9 Gh Kn Lt","40002676","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 13Mm Persona 6-9","40002678","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 10 Nar Kn Rt","40002679","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Std Kn Rt","40002680","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3258","3258","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc 10Mm Persona 6-9","40002681","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stm 45Mm Nxgn Kn Tib","40002682","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tib 5Mm Nxgn Kn Prect","40002683","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1233","1233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 32Mm Nxgn Prlng","40002684","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Ptlr 29Mm Nxgn Prlng","40002685","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem E- Kn Rt Cmnt","40002686","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 5-6 E-F 17Mm Kn Fx","40002687","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 24Mm Dart-Fire Ti","40002688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","701.4","701.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Actb 54Mm Hip 5 Scr Hl","40002689","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1739.77","1739.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trident 10 X3 Insrt 36Mm Id","40002690","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1242.11","1242.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 7 L114Mm Nk L37Mm","40002691","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2827.5","2827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Cd","40002692","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm 11Mm Prm Vrsy","40002693","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3236.63","3236.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 57Mm Mlplr Hip Mtl","40002694","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Bp 57/58Mm 28Mm Vrsy","40002695","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 40Mm Hip Unplr","40002696","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 38Mm Mlplr Hip Mtl","40002697","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","719.25","719.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Bp 38Mm 22Mm Lgc Hip","40002698","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Artc 3-4 C-D 12Mm Kn Fx","40002699","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1897.09","1897.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 12/14 50Mm Hip Unplr","40002700","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Hd Vrsy Lgc +7Mm 12/14","40002701","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bp 41Mm Mlplr Hip Mtl","40002702","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","823.2","823.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 140Mm 15Mm Prm Vrsy","40002703","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5442.94","5442.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L6 Dia2 Slf Drl","40002704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L8 Dia2 Slf Drill","40002705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 2.4 Dia 4 Lgth Un","40002706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L6 Dia2.4 Slf Tap","40002707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L8 Dia2.4 Sel Tpp","40002708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Expandable Pstr L","40002709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1140","1140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullry L380 D9 130","40002710","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3119.31","3119.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L400 D9 Lf","40002711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2668.59","2668.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L270 D12 Sterile 3 F","40002712","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1040.16","1040.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Joint Device (Implantable)","40002713","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3855.6","3855.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tensioner Surgical Fluted Knob","40002714","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","5109.43","5109.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lock Cable Dia1.7 Fluted Knob1","40002715","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1081.35","1081.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Drill L198 D5.6/3.2","40002716","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","185.2","185.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Condylar Rt 12 266","40002717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2588.81","2588.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X40 Cortical Hex","40002718","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.85","46.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Fibertape Non Abs L2 St","40002719","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","434.07","434.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Arthroscopic D1.35 P","40002720","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","108.65","108.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X28 Patellar Lag C","40002721","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 105Mm Prft Acld Ii","40002722","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2912.98","2912.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002723","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1710.45","1710.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002724","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 75 Ss T15 Tib","40002725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","290.81","290.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 90Mm Ss T15 St","40002726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.42","324.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx 5Mm Securestrap 25","40002727","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","838.81","838.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Fx 5Mm Securestrap Abs","40002728","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","744.07","744.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Srg Bard 3Dmax 6X4In R","40002729","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","448.98","448.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill D2.7 For Cannula Scr","40002730","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","594.34","594.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic D1.4 Gold","40002731","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","52.5","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic D1.9 Gren","40002732","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mini L40 D4 Sht Thc","40002733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50 D5.5 Self Drill","40002734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","910.43","910.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24 Fully Thread","40002735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L35 D3.5 Dist Fblr","40002736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L37.5 D3.5 Distal F","40002737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic Olive Th","40002738","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.7 Standard Maxl","40002739","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","558.6","558.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 8 L139Mm Nec","40002740","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2565","2565","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Inflation 20Cc Upto 30A","40002741","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","181.05","181.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002742","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 108Mm Prft Acld Ii","40002743","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3147.71","3147.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Fx Tghtrp Xp Ss","40002744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2276.14","2276.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 12 Hole Third Tubul","40002745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 16Mm Ss T10 Ft","40002746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X18 Cortical Nls","40002747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22 Cortical Nl","40002748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","119.25","119.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18 Cortical F T","40002749","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","87.5","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 130 200 6","40002750","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2625.75","2625.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ring Annuloplasty 32Mm Mitral","40002751","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Size 9 L140 D12.6","40002752","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2345.61","2345.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16Mm Od3.5 Neon3","40002753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.75","1338.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal W16.5Xl45 Thk2 L3","40002754","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.75","1338.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L12 Od4 Dark Bl","40002755","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14 Dia4 Ant Cv S","40002756","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","267","267","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16 D4 Ant Cerv","40002757","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","268.99","268.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50 D6.5 Gr Ply","40002758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10 Cortical Hex","40002759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12 Cortical H","40002760","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Femoral Od11 Univ Hip C","40002761","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","278.25","278.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal Sm 24-30 Ocpt","40002762","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1254","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 12 Hole Third Tubul","40002763","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary 300 10 130","40002764","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod External Fixation W114Xl22","40002765","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","962.83","962.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14 Dia3.5 Noen3","40002766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.75","1338.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor Surgical 22X50 Ass B","40002767","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2613.62","2613.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shim Spinal 11/13X29 6Deg Flhk","40002768","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L142 6 Hole Lock Va","40002769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2236.64","2236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L110 Dia2.3 Gold Q C","40002770","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","123.53","123.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannulated Screw Blunt Tip 4","40002771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L Extreme Right Cal","40002772","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2046","2046","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Standard Extreme Rt","40002773","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2046","2046","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Non-Locking 3.5X30","40002774","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.56","363.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac Joint 7X85","40002775","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4869.38","4869.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac Joint 7X90","40002776","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4731.56","4731.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 365Um","40002777","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2804.05","2804.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox L 4","40002778","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3792.3","3792.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia10Mm","40002779","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Vascular L80 Dia7 Cath 1","40002780","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3475","3475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Arterial Work 110 60","40002781","CDM","278","RC","C1761","HCPCS","","","facility","both","","","","3609.38","3609.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 135 60 10","40002782","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","280.58","280.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 135 60 12","40002783","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","280.58","280.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Tbg Aquilex Y Fl Cntrl","40002784","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Thrombectomy L105 D16","40002785","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","9187.5","9187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Blndil 8 135 5","40002786","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","150.54","150.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filler Bn Void 10Cc 25Cc Ca","40002787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2599.71","2599.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blde Surg L90Mm Dia10.5Mm","40002788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","899.01","899.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blanket 74X24In Adlt Br Hgr","40002789","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","26.27","26.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shaver Quadcut L13 Cm Od","40002790","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","927.92","927.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 13Mm Zevo Ti","40002791","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","511.58","511.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Fml 10-12 14","40002792","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fx 1.1Mm 150Mm Krsh Troc","40002793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.73","113.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fld Mgmt Fluent Flopak Bg","40002794","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2380.66","2380.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bag Wst Mgmt Fluent Fld Disp","40002795","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","687.83","687.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trap Spec Rem Tiss Fluent Fld","40002796","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","206","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X40Mm Compr","40002797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","743.48","743.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ascp Fx Fibulink Ss","40002798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2154.24","2154.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40002799","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7087.5","7087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Anat Cerv Cage L","40002800","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4368.01","4368.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Canc 15Cc 4-10Mm","40002801","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","404.02","404.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal Medial Opn 2","40002802","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2600.25","2600.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allocell Morphogenetic Protein","40002803","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","6121.5","6121.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Od7Mm Polyax","40002804","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 40Mm 5.4Mm Romeo Post","40002805","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 15.66-10Mm 360Mm Fem Rt","40002806","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 50Mm Ti T25 Ft","40002807","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","228.25","228.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Orth Ss 1.7Mm 750Mm Crmp","40002808","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","856.06","856.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 9Mm 315Mm Tib Xprt Im Rnd","40002809","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L22-32Cm","40002810","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","150.48","150.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blde Surg L110Mm Dia10.5Mm","40002811","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","888.35","888.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 10Mm 380Mm Fem Rt Prox","40002812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth Sprfc Fem Art Ilc","40002813","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5275.62","5275.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bn Traumacem V+","40002814","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","928.53","928.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 12.7Mm 8Mm 2.7Mm 80Mm","40002815","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","564.67","564.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 30Mm Ti T25 Ft","40002816","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","238.37","238.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Tfn-Advanced T-I6Al","40002817","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","925.24","925.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 38Mm 2.5Mm","40002818","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.68","75.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 142Mm Ss 2.7/3.5Mm Scr 6","40002819","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2090.91","2090.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 36Mm Ss Ped T8","40002820","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.68","75.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 24Mm Ss T15 St","40002821","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","362.02","362.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 26Mm Ss T15 St","40002822","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","372.56","372.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 38Mm 2 Lvl Tryptik 2 Bn","40002823","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im Nl Tn 105Mm 10.35Mm","40002824","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","888.35","888.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw, Lag 95Mm","40002825","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","885.4","885.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fixat L100Mm Dia5Mm","40002826","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.26","207.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fixat L60Mm Dia4Mm","40002827","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","193.98","193.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail 9 Mm Length 345Mm","40002828","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4119.58","4119.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Screw For Im Nail 5 38","40002829","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Low Prof Lckng Screw 5.0 38 25","40002830","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","603.25","603.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Low Prof Lckng Screw 5.0 30 25","40002831","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","594.71","594.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail 11 Mm Length 360","40002832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3961.13","3961.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X44 Xl25 Recess Ti","40002833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","841.43","841.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X48 Xl25 Recess Ti","40002834","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.8","793.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X36 Xl25 Recess T","40002835","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","957.26","957.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X42 Xl25 Recess Ti","40002836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.58","965.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X48 Xl25 Recess Rf","40002837","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","960.96","960.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Vein Clsr Venaseal","40002838","CDM","278","RC","E0783","HCPCS","","","facility","both","","","","1461.6","1461.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Scr Spnl Lum Post Ellipse","40002839","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shim Spnl 10/12X29Mm 6Deg","40002840","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4382.44","4382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sling Urth Supris Thk.3Mm","40002841","CDM","278","RC","C1771","HCPCS","","","facility","both","","","","1494.67","1494.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 1/3 Tblr 93X9X1Mm Ti","40002842","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.35","335.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 2.9Mm 14Mm Ti T","40002843","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","216.76","216.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 14Mm Ti 2.5","40002844","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.12","48.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Doublewire 6 Be-2 14In","40002845","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1681.98","1681.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Tiss 5X4In Drgn + Dura","40002846","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","2730.9","2730.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrgrade Femoral Nail 11 340","40002847","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4732.88","4732.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Surg Hi Pwr Holm","40002848","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1541.84","1541.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Surg Holm","40002849","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","901.26","901.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Id Crv Por Ti Spcr 6X16X14Mm10","40002850","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Id Crv Por Ti Spcr 7X16X14Mm10","40002851","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1807.04","1807.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L39Mm Nit Ant Crv3","40002852","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1805.03","1805.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14Mm Dia4Mm","40002853","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","334.26","334.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60 Xl25 Strl","40002854","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X66 Xl25 Strl","40002855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70 Xl25 Strl","40002856","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X80 Xl25 Strl","40002857","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32 Xl25 Strl","40002858","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L80 D8 Iliac Ply","40002859","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L55 D6.5 Grn Poly","40002860","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1825.04","1825.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 Dia7.5 Blue P","40002861","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1725.47","1725.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 Dia7.5 Blue P","40002862","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L90 Di8 Iliac Pol","40002863","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.19","1878.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Acss Vrble 3.5 14","40002866","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","443.42","443.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Acss Varbl 4.0 16","40002867","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","456.33","456.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16 Od4 Vr Agle","40002868","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","329.18","329.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L20 Anterir Cev 1","40002869","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Drill D2.4 With Sc 30 1","40002870","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","566.18","566.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X6 Cortical T6 Sd","40002871","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X7 Cortical T6 Sd","40002872","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X8 Cortical T6 St","40002873","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X9 Cortical T6 Std","40002874","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X10 Cortical T6 Rs","40002875","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.4","96.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X6 Cortical T6 Std","40002876","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X7 Cortical T6 S","40002877","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X8 Cortical T6 Std","40002878","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X9 Cortical T6 Sd","40002879","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X10 Cortical T6 S","40002880","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.88","175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 Hole 45 Tit M Min","40002881","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","401.16","401.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 7 Hole 52 Tit M Mi","40002882","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","401.16","401.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Condylar 2X7 Hole 5","40002883","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","966.74","966.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 12 Hole Adaption 81","40002884","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.66","726.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Condylar 7 Hole 66M","40002885","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","843.62","843.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50 D6.5 Postr Cb","40002886","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 D6.5 Postr Cb","40002887","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L35 D5.5 Antr Postr","40002888","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","940.5","940.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal 22X13X9 Stnd 4 Deg","40002889","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7350","7350","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Venous Slf Expd 14X60 80","40002890","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Venous Slf Exp 14X60 120","40002891","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon Rt 2 H 90","40002892","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1541.57","1541.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X38 Cortical T8","40002893","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","111.73","111.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L300 D1.5","40002894","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","432.96","432.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L440 D2.5","40002895","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.55","496.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420 D9 130Deg Lng Fem","40002896","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3119.31","3119.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal H5-7 6Deg Stand T","40002897","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W15.5Xh6X3.1 D12","40002898","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2100","2100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Awl Plate Short Starter H5-7","40002899","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tibial Xsm Thk 5 Right","40002900","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Sz 5 L120 Neck 39","40002901","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2565","2565","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14Xh6Xl12 7Deg","40002902","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L10 Anterior 1Lv","40002903","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surgical L14 Od4 Ant Cer","40002904","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14 Od4 Anter Inb","40002905","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5 Dia 14 Ply Ca","40002906","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1450.78","1450.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L20 Di3.5 No1 Ply","40002907","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L32 D3.5 No1 Ploy","40002908","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1502.55","1502.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L32 D5 No2 Ply","40002909","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 12Mm For Ria 2 Bon","40002910","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","987.39","987.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L200 D4 Titanium St","40002911","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Cervical 14 12 5","40002912","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3412.5","3412.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Cervical 14 12 6","40002913","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L18 D4 Ant Cv S D","40002914","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.67","270.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Vbr 16X13 0Deg Oval Angu","40002915","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3380.74","3380.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Vbr 16X13Mm 10Deg Oval A","40002916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.38","3189.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L30 Od5.5 Can N3","40002917","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L240 Od4 Cocr Neon3","40002918","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Locking Neon3","40002919","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 50Mm 3.5Mm Vrtx Slct","40002920","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","745.14","745.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Set Ti M6 Spne Btrs Thrd","40002921","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","147.85","147.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm 11Mm Prm Cmnt","40002922","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2568.75","2568.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Piranha Tubing Set","40002923","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","125","125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L65/39 D1.1 For 1.5","40002924","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","171.02","171.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc 30Cm 22Mm Hmsh Pl","40002925","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","899.23","899.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Spnl Fx 50Mm 7Mm","40002926","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4731.56","4731.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia1.8Mm With Add","40002927","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","975.2","975.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 16Mm Loprfl Scr","40002928","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W22Xl54Mm Std 9 H L","40002929","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.8","1241.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Tensix Dbm 2.5Ml","40002930","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2195.4","2195.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 29Mm 7Mm 11Mm 7Fr","40002931","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4411.31","4411.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 45Mm 5.4Mm Romeo Post","40002932","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy Acquire Fine Od2","40002933","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy Acquire Fine Od2","40002934","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","464.93","464.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retriever 180Cm 10Fr Gw Stnt","40002935","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","309.41","309.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 286Cmx9Mm Spgl Escp Strl","40002936","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","919.5","919.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fx 1.6Mm 150Mm 25Mm Lcp","40002937","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","94.64","94.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 34Mm Ti T8 St","40002938","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","224.22","224.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 28Mm Ti T8 St","40002939","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.67","237.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Sut Pro Sys Novostitch","40002940","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","912.77","912.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cartridge Novostitch + 2-0 Sut","40002941","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","858.38","858.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 12D 2-0 Truspan","40002942","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","963","963","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia7Mm Ant","40002943","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","319.2","319.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Ha 25Mm 7Mm Acl","40002944","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem -5Mm Ofst Tpr 36Mm","40002945","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1258.4","1258.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Actb Trdnt 10D E 36Mm X3","40002946","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 6Mm 50Mm Romeo Spne","40002947","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bn Plc R 40Gm Grn","40002948","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carrier Graft Pvc 1.5: 1 L8 In","40002949","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","98.82","98.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carrier Gft Msgrft Ii Drmcr Ii","40002950","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","82.5","82.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaver Tissue Removing 10Mm","40002951","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1535.28","1535.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L80 30 5","40002952","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L34Mm 6 Hole Ante","40002953","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500 D5.5 Cobalt St","40002954","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Z Rod Spinal L300 Dia6 L Blue","40002955","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.5","1012.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia9Mm 130Deg","40002956","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3119.31","3119.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 550Um Holm","40002957","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4.7 Standard 1/4","40002958","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","741.3","741.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bipolar Od41 Id28 Fem Rus","40002959","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","964.3","964.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Radius Distal 6X4","40002960","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1243.65","1243.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tib Infnt 4 Ankl Adaptis","40002961","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11392.94","11392.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dome Tlr Infnt 3 Ankl Flt Cut","40002962","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11745.09","11745.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Cortical 3.5 D15 Cn","40002963","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 10Gm Voi","40002964","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2610","2610","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L10 Titanium Po C","40002965","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","818.08","818.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal H14 15Deg Anterior","40002966","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10500","10500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25 D5 Scar","40002967","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32.5 D4 Sht Cann","40002968","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L37.5 Dia5.5 Sf Dr","40002969","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 10-11 Tib","40002970","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp Brn 49Mm 28Mm Slfcntr","40002971","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +5Mm 12/14 Tpr 28Mm","40002972","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","924.68","924.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 1.85Mm 6Mm Matrixwave","40002973","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.72","219.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8 Dia1.85 Titanium","40002974","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","220.45","220.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 10H Maxillomandibular","40002975","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","501.76","501.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Matrixmidfc L44.5Mm","40002976","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","275.02","275.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Matrix 8Mm Stp L44.5","40002977","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","275.02","275.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Crstn L-Asr Cort 11Mm","40002978","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2316.1","2316.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib 7Mm Infnt 3+ Ankl","40002979","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3990.11","3990.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L35Mm Od5.4Mm","40002980","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Band Connector Single Flx 2.0","40002981","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4117.84","4117.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L15 Offset Mo","40002982","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L30 Offset Mo","40002983","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.19","1878.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal Parall 5.5/6","40002984","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal M Dia3.5-4","40002985","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1693.13","1693.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L10 Dia3.5/4","40002986","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1769.32","1769.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L360 D9 Ti","40002987","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1657.36","1657.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X30 Cancellous Can","40002988","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.26","364.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedullary L380 D9 Gr","40002989","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1799.58","1799.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X32 Cortical T8","40002990","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.08","196.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty L80 20 7","40002991","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Cervical Spacer","40002992","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acss 12Mm Zero Plate","40002993","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Monocryl 2-0 27In Absor","40002994","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","254.88","254.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap 4.5Mm Sgl-Use Cannulated","40002995","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","836.98","836.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap 5.5Mm Sgl-Use Cannulated","40002996","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","836.98","836.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Sz 7 L130 Od10.4M","40002997","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2443.5","2443.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L330Mm Dia10Mm","40002998","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.6","1451.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Tubing Aquilex Fluid Contr","40002999","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stm 10Mm Cmntrlzr","40003000","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","278.4","278.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 4 L114Mm Nk L34Mm","40003001","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2608.97","2608.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od44Mm Id28Mm Fem","40003002","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","937.01","937.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Dia28 Neck L+1.5","40003003","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 40Mm Ti T25 St","40003004","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","353.64","353.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 90Mm Antirotate Strl","40003005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","455.66","455.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 130D Ti Niobium Al Fem","40003006","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","933.43","933.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Orth 85Mm Ti Aly Fem Nk","40003007","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","675.81","675.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 85Mm Tfn-Adv","40003008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","911.96","911.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 3.9Mm 38Mm Ti","40003009","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","600.12","600.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 7Mm 50Mm Romeo Spne","40003010","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"29 Mm Shell Tall","40003011","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4382.44","4382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allocel Bone Graft Medium Kit","40003012","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2941.5","2941.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shim Spnl 8/11X29Mm 0Deg","40003013","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4382.44","4382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 21Mm Ti 1 Lvl Zevo Bn","40003014","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2794.43","2794.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 189X11X3.4Mm Ss 3.5Mm","40003015","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","811.82","811.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Infnt Spne","40003016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1615.95","1615.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Biopsy 18Ga L10 17 6.8","40003017","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Biopsy 18Ga L20 17 16.8","40003018","CDM","272","RC","A4215","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trnscrd L40Mm Dia9Mm Cth","40003019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3596.91","3596.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L100 Mm Antirotate","40003020","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.76","442.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ttnm  L42Mm Od4.5Mm","40003021","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","355.83","355.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L24Mm Ant","40003022","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2100","2100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L50Mm Dia4Mm Ti Lrd","40003023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl L18Mm Di3.5Mm 1Plyax","40003024","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1487.09","1487.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Sp L38Mm D3.5Mm 1Plyx Ss","40003025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Sp L40Mm D3.5Mm 1Plyx Ss","40003026","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw","40003027","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.25","278.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cylinder Penile Pros L16Cm","40003028","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","14621.25","14621.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosthesis Penile Plg Infl","40003029","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 10-11 Tib","40003030","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 85X11X3.4Mm Ss 3.5Mm Scr","40003031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","573.8","573.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 111X11X3.4Mm Ss 3.5Mm","40003032","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","610.09","610.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allocell 10Cc","40003033","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allocell 10C","40003034","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surgical L120 D10.5 N Ti","40003035","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","888.35","888.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Femoral 3 Offset Hip 12","40003036","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","313.21","313.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Unipolar D43 Hip Ball Mod","40003037","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","950","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif Sa 10 Deg 6","40003038","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7546.88","7546.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif Sa 20 Deg 8","40003039","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7875","7875","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif Lateral 5 25","40003040","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif Lateral 5 30","40003041","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","954","954","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40 D5.5 Cort Can","40003042","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W10Xh14Xl25 10 T","40003043","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4813.41","4813.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln Dlttin L17Mm Dia6Mm","40003044","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","1269.93","1269.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc H12Mm R Knee","40003045","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L22Mm Dia3.5Mm Ttnm","40003046","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24Mm Dia3.5Mm Cor","40003047","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X34Mm Dst Fem Cort","40003048","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia3.5Mm Tita","40003049","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia3.5Mm Cor","40003050","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia3.5Mm Cor","40003051","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32Mm Dia5Mm Dst","40003052","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Screw Dia8Mm Hex Dia3.5Mm","40003053","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","394.8","394.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia5Mm Std","40003054","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","422.1","422.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L245Mm 9 H St","40003055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2476.5","2476.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Troch R Nar Ncb","40003056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1924.65","1924.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Cable Hex 3.5Mm Titanm","40003057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L24Mm Dia4.3Mm Ncb","40003058","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artcular Femoral 3-5","40003059","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22Mm Dia2.7Mm","40003060","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.75","101.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L46Mm Dia3.5Mm Thrd","40003061","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L65Mm Dia7Mm Sht Th","40003062","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia7Mm Slf Drl","40003063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.4Mm Standard Ma","40003064","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","558.6","558.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fmrl 10-11 H11Mm","40003065","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spinal 30X39Mm 6Deg","40003066","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6618.94","6618.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tibial Size G Right","40003067","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3668.18","3668.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ex Stem L135Mm D16Mm Femoral","40003068","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2977.7","2977.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artcular Femoral 10-12","40003069","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3961.13","3961.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant/Insert Device, Noc","40003071","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Protct For 5Mm Fix Pin","40003072","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","70.12","70.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Compr","40003073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","770.2","770.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh11Xl24Mm","40003074","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3281.25","3281.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L100Mm Dia6Mm Lt","40003075","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L90Mm Dia4Mm Ti","40003076","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L110Mm Dia4Mm Ti","40003077","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spinal Extended","40003078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.25","278.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L10Mm Dia3.5Mm","40003079","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal L Head To Hea","40003080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1794.72","1794.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L30Mm Dia4Mm","40003081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X32Mm Multiloc","40003082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.69","335.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia4Mm Tib Bl","40003083","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","238.37","238.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 270Mm 3.8Mm 3 Flut Qc","40003084","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","327.27","327.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 413Mm 4.3Mm","40003085","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","710.05","710.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L30Mm D3.5Mm Ocpc","40003086","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1615.95","1615.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X26Mm Occptcrv","40003087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1615.95","1615.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L25Mm D3.5Mm Ocpcrv","40003088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1254","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Actb Trdnt 10D D 5.9Mm","40003089","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X18 T6 Stardrive R","40003090","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","236.08","236.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W16Xh8 D14 10Deg","40003091","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L28 Titanium Niti","40003092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.19","1504.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Dril Cervical 3.5 12","40003093","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.46","467.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16 Od4 Tit Drl S","40003094","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","334.26","334.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Cervical 10 7 18","40003095","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Cervical 3.5 12","40003096","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Cervical 3.5 16","40003097","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Cervical 4.0 14","40003098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","466.2","466.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45 D5.5 Cort","40003099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Polyaxial 6.5 40","40003100","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3018.75","3018.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L90 D8.5 Cort","40003101","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral Sz 9 L120Mm Nk","40003102","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2969.54","2969.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mmx16Mm Ped","40003103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mmx18Mm Ped","40003104","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.02","1370.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mmx20Mm Ped Cv","40003105","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mmx26Mm Ped Cv","40003106","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Opn-Offset 10Mm","40003107","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1040.55","1040.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 3.5Mmx50Mm  Crvcl","40003108","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 10Deg 10Mmx16Mm","40003109","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crvcl Sa Bn Scrw Sdva 3.5X14Mm","40003110","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 9X22X7-10.5Mm 3D","40003111","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8695.32","8695.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L30Mm Od5.5Mm Ticp","40003112","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","682.5","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L35Mm Od5.5Mm Ticp","40003113","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","682.5","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast Tisse Exp Sut Tab Integ","40003114","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2218.75","2218.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L18Mm Dia2.5Mm","40003115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","678.3","678.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L70Mm Od5.4Mm Perc","40003116","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Distal 18.5Mm","40003117","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inlay Intvrtb Disc 8.5Mm Activ","40003118","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1251","1251","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Actb 56Mm Hip 5 Scr Hl","40003119","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1761.76","1761.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Actb 36Mm 10D Hip X3","40003120","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Strg 91X10.2X2.7Mm Ss","40003121","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","736.56","736.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 38Mm Ti T25 St","40003122","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","355.03","355.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 85Mm Antirotate Strl","40003123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","455.66","455.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 45Mm 2.5Mm","40003124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","62.52","62.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 1.5Mm 10Mm Ss T4 Cort","40003125","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.13","90.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 1.5Mm 11Mm T4 Cort St","40003126","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.13","90.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 1.5Mm 8Mm Ss T4 Cort","40003127","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.13","90.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn Blu 9Mmx.4Mm","40003128","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","190.84","190.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Bn Cmnt Traumacem V+","40003129","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","882.94","882.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.5 Mm L44 Mm Od4 Mm","40003130","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","56.3","56.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn Lcp L40Mm Od4Mm Odsc6","40003131","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","56.3","56.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.5X5Mm Cmf Ft Slf","40003132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","226","226","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5Mm X 40Mm Ply","40003133","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia5.5Mm","40003134","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45Mm Dia6.5Mm","40003135","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal 11 Open Rev I","40003136","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","930.62","930.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L20 Poster Ti","40003137","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.95","953.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500 D5.5 S Post Ti","40003138","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Dril Cervical 3.5 16","40003139","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","458.64","458.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Slf Drill 4.0 14","40003140","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","494.17","494.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Center Spinal Alif 5Mm","40003141","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Center Spinal Alif 5 25","40003142","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Graft Spinal Alif 8.5Mm X","40003143","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1819.13","1819.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicle 3.5 58","40003144","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicle 3.5 30","40003145","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicle 3.5 30","40003146","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Posterior 5.5","40003147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","217.17","217.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Cervical 3.5 X 25","40003148","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Subaxial 2.1Mm Steri","40003149","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","218.2","218.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Holmium 550","40003150","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Xtrnfx Lg Opn Adj Mr","40003151","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","805.01","805.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Extr Bg 6500Ml Rng","40003152","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1057.5","1057.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Actb 50Mm Hip 3 Scr Hl","40003153","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1730.98","1730.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem +0Mm Ofst Tpr 32Mm","40003154","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Xtrnfx 100Mm Fem Nk Sys","40003155","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","647.12","647.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 42Mm Ti T25 St","40003156","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.4X105Mm St Fem Nk","40003157","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890","890","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 6Mm 45Mm Romeo Spne","40003158","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L75Mm Od5.4Mm Post","40003159","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Subaxial 2.1Mm Steri","40003160","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","436.36","436.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W16Xh7 D14 7Deg","40003161","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L30 Titanium 2","40003162","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1504.19","1504.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L14 D2.3 Stain","40003163","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","191","191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X20 Cancellous T","40003164","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","85.63","85.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18 D2.7 Cort Tit P","40003165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","821.1","821.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X10 Compression Hd","40003166","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Insuled Safeop","40003167","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2160","2160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40Mm Dia6.5Mm","40003168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia6.5Mm","40003169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","902.51","902.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45Mm Dia6.5Mm","40003170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","902.51","902.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Polyaxial Modular","40003171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","934.67","934.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 18 Nitinol Trocar Tp","40003172","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","198.05","198.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Vi2 5.5Mm X65Mm Ti","40003173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","691.93","691.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X34Mm St T25","40003174","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.71","346.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003175","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2443.1","2443.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 250Mm 2.8Mm 95Mm Qc","40003176","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","184.89","184.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia5Mm St","40003177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","585.5","585.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia5Mm St","40003178","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","604.4","604.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L85Mm Dia5Mm Carb","40003179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90Mm Dia5Mm Carb","40003180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","369.54","369.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia5Mm Carb","40003181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.62","348.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L55Mm Dia5Mm Carb","40003182","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","369.54","369.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acetabular Size C D48 G7","40003183","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4027.8","4027.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral L109 D5 134 Ml","40003184","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2815","2815","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X72Mm Sterile Xl25","40003185","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X34Mm Sterile Xl25","40003186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X40Mm Sterile Xl25","40003187","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L200 Dia2.8 Calb 110","40003188","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","304.98","304.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Reaming 2.5 Mm W/Ball Tip","40003189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","187.75","187.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46 Compression Hd","40003190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw External Fixation L150","40003191","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","221.6","221.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 6.5X50 Nw Cortical Poly","40003192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bn 3H 1/3Tblr W/Cllr 33Mm","40003193","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","260.38","260.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn W10.2Xl65Mm Thk2.7Mm","40003194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","597.98","597.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail 12 Mm Len 360 Mm","40003195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4159.31","4159.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X40Mm St Xl25","40003196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","586.17","586.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X34Mm St Xl25","40003197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","586.17","586.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 251Mm 10.2Mm Cnn","40003198","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","809.99","809.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 13.5Mm Ria 2 Bone","40003199","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","931.5","931.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Alf Sa8X34X24Mm 15","40003200","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7999.69","7999.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Alf Sa8X34X24Mm 20","40003201","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7875","7875","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W16Xh7Xl14Mm 7D","40003202","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bolt Spinal Alif Sa 8.5","40003203","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1819.13","1819.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bolt Spinal Alif 8.5 30","40003204","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1819.13","1819.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Size C D38 G7","40003205","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acetabular Od38Mm Id28 C","40003206","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1941.97","1941.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Attachment Washer Retr","40003207","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrograde Femoral Nail 10 340","40003208","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4732.88","4732.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Prox 10 340 Fem Rt","40003209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817.45","2817.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Cement 10Ml Inj Incl Mix","40003210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","899.1","899.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Temp Fix For Trestle","40003211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","165.54","165.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Illumination Lif","40003212","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","814.27","814.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L35Mm Dia5.5Mm","40003213","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500Mm Dia5.5Mm","40003214","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L80Mm Dia8.5Mm","40003215","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ti 7.5Mm X 45Mm","40003216","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3018.75","3018.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Positioning Va 5.0 Plate","40003217","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","401.31","401.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L28Cm Dia14.5Fr Insrt","40003218","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 112Mm Ss2.7/3.5Mm Scr Lt","40003219","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2068.42","2068.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L40Mm Od6Mm Pedcl","40003220","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Lcp 134Mm X W13.5Mm","40003221","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","793.27","793.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp Blu 52Mm 28Mm Slfcntr","40003222","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1181.92","1181.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bn Vivigen Matrix 5Cc","40003223","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4096.57","4096.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L94Mm 10 H Bilat Ss","40003224","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","725.15","725.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Arthx Fibertak Strl","40003225","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 54Mm Ss 2.4Mm Scr 6","40003226","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1222.62","1222.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 300Cm .018In","40003227","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gd 45Cm 6Fr .109In .087","40003228","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","221.54","221.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 45Cm 4.7Mm 12Fr","40003229","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","977.85","977.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 300Cm .014In","40003230","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Gd 70Cm 8Fr 2.9Mm Flxr","40003231","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Cath 90Cm 6.5Fr","40003232","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 19Mm 6Mm 8Mm 7Fr","40003233","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3802.31","3802.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Embl 30Cm .02In 6Mm","40003234","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1559.25","1559.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fixation L24 D2.5 Dvr","40003235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","248.04","248.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 2.9Mm 18Mm Ti T","40003236","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","212.18","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 16Mm Ti T15 Ft","40003237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","212.18","212.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 4.4Mm 40Mm Ti 3.5","40003238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.8","373.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn L220Mm Lt 5Mm Lck T9","40003239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2772","2772","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn L316Mm Lt 5Mm Lck F13","40003240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2772","2772","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 5Mm Lck Lt L236Mm F9","40003241","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2772","2772","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pack Btry Li Precharge Pwr","40003242","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","221.76","221.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L4Mm Dia1.5Mm Sil Ti","40003243","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","192.54","192.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 14Mm Ss Ped T8","40003244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","81.28","81.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer 7Mm 3.6Mm Sm Lcp Orth","40003245","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.94","53.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bne 40Gm Fll Dose Pmma","40003246","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","932","932","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 10Mm 380Mm Fem Lt Prox","40003247","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2986.5","2986.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003248","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","741.3","741.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia4Mm For Ant Talar","40003249","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","349.44","349.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Sw .315In Unv Nar Stryk","40003250","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","560.95","560.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","142.5","142.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Dia32 +4 Offset","40003253","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia5Mm Cann For 7Mm","40003254","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","707.87","707.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fx 1.6Mm 5In Krsh Ss Bn","40003255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","190.8","190.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Loprfl Scr","40003256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","87.5","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 14Mm Loprfl Scr","40003257","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2.7Mm Ank","40003258","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Od2 Mm","40003259","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","195.7","195.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Od2.5 Mm","40003260","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","175.1","175.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vascular 260 035","40003261","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","121.9","121.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr 100Cm Ad","40003263","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","33.36","33.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L150Cm Ballon","40003264","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Sprt 150Cm 1.5Fr","40003265","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","355.96","355.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Vasc 12Fr 20Cm Radopq","40003266","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","23.34","23.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili Ad L30Mm Dia1.67Mm","40003267","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bil L4Cm 10Fr L165X210Cm","40003268","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 2.1Mm 12Mm Ti","40003269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","207.76","207.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Thk0.8Mm Orbit","40003270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1817.27","1817.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Gi L10Mm Dia20Mm W/ Elec","40003272","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","7068.6","7068.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 16Mm Ti 2.5","40003273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.65","48.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 1.5Mm 12/14 Tpr 28Mm","40003274","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1081.2","1081.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pncr 7Fr 9Cm 1 Pgtl Crv","40003275","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Dlv 7Fr Rx Naviflex","40003276","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","176","176","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 7Mm 60Mm 16Mm Darco","40003277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2032.5","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 7Mm 65Mm 16Mm Darco","40003278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2032.5","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail 10Mm 360Mm Fem Lt Prox","40003279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2817","2817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Tiss 5X4In Drgn Dura","40003280","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","3066.43","3066.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 62Mm Ss 3.5Mm Scr 3 Hl","40003281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","951.6","951.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ti 7.5Mm X 40Mm","40003282","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3018.75","3018.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone  3.5 Mm Lokcing","40003283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","301.27","301.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Crv 266Mm Ti 4.5Mm Scr","40003284","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3169.47","3169.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 108Mm Rds Crv 182X10.2","40003285","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","951.6","951.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 11.5X90Mm","40003286","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4800.47","4800.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia2.5Mm Std","40003287","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","234","234","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia2.5Mm Std","40003288","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","268.8","268.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 30Mm 2.5Mm","40003289","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 40Mm 2.5Mm","40003290","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.16","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 6.5Mm 32Mm Ti","40003291","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.88","46.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 6.5Mm 66Mm Ti","40003292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.88","46.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 6.5Mm 68Mm Ti","40003293","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.88","46.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.5Mm 6.5Mm 70Mm Ti","40003294","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.88","46.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L34Mm Dia4.5Mm Cort","40003295","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.69","49.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L86 Mm Fbla Left 4H","40003296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","817.16","817.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube 10Cm 20Fr Bln Rtnt Infd","40003297","CDM","272","RC","","","","","facility","both","","","","172.64","172.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L30Mm Dia6.5Mm Grn","40003298","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.19","1878.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L60Mm Dia6Mm Lt Blu","40003299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia6Mm Lt Blu","40003300","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap 7.5Mm Sgl-Use Cannulated","40003301","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire 1.5Mm 500Mm Len Nit","40003302","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","157.76","157.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Lordotic Exp 7X10X25Mm 20D","40003303","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9043.13","9043.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod V12 5.5Mmx65Mm Lordotic","40003304","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","9043.13","9043.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Lordotic Exp12X10X30Mm 20D","40003305","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8531.25","8531.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R Dst Fblr 6H Lok Ss","40003306","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1249.5","1249.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 13 L135Mm L38.5Mm 135","40003307","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3241.88","3241.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Uplr Dia53Mm Hip Mod Cath","40003308","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","950","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wallflex Duod Sft 27/22Mm 9Cm","40003309","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3135.56","3135.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrogrd Fem Nail 10Mm 360Mm","40003310","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5267.28","5267.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt L161Mm Dia34Mm Shth","40003311","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22896.71","22896.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt L154Mm Dia34Mm Shth","40003312","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","24036.34","24036.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt L79Mm Dia34Mm Prox","40003313","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","24036.34","24036.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L14Mm Ant Cerv","40003314","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Infinity 4 Long Ankl","40003315","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11392.94","11392.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia4Mm Lng","40003316","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1653.75","1653.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L45Mm Dia4Mm Lng","40003317","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1105.05","1105.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32.5Mm Dia4Mm Lng","40003318","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2008.13","2008.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft L109Mm Dia28Mm Aort","40003319","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","15316.88","15316.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft L76Mm Lg L28Mm Dia 12Mm","40003320","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5319.63","5319.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft L56Mm Dia24Mm Shth","40003321","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5089.88","5089.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum L122Mm Dia14Mm Std","40003322","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4521.57","4521.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Spcr Acss 06Mm Dol","40003323","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2672.25","2672.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Spcr Acss 07Mm Dol","40003324","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2690.62","2690.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X58Mm Xl25 Recess","40003325","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","437.55","437.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 5 H Dst Fblr","40003326","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1087.5","1087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X28Mm Cort Ft","40003327","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","87.5","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 5Cc Calc","40003328","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1872.32","1872.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ti 1Hl Fem Nk Strl","40003329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","934.82","934.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Nphstmy L15Cm Blln Dia8Mm","40003330","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","677","677","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 10.35Mm 90Mm Tfn-Adv","40003331","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","903.11","903.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Sm 10 Hole Maxillom","40003332","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","532.67","532.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 18Mm Dart-Fire Ti","40003333","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","701.4","701.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Arthx Fibertak Rotr","40003334","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","808.5","808.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hernia Xl W10.8Xl13.7In","40003335","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2942.83","2942.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blde Surg L85Mm Dia10.5Mm","40003336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","919.97","919.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 12Mm Ti Cort","40003337","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","175.96","175.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.3Mm 16Mm Ti Cort","40003338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","271.57","271.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.3Mm 10Mm Ti Ft Cort","40003339","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.3Mm 12Mm Ti Ft Cort","40003340","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","271.57","271.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.3Mm 14Mm Ti Ft Cort","40003341","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","271.57","271.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Ti L16Mm Od2.3Mm","40003342","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","271.57","271.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ti L68Mmxw11Mm Lt 13","40003343","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2252.16","2252.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia6.5Mm Cort","40003344","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","911.63","911.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax Mod Tulip","40003345","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","891.38","891.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brush Cyto 3Mm 7Fr 240Cm Brstl","40003346","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","46.1","46.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Pleurx Pleural","40003347","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","905.63","905.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing Aquilex Fluid Contr","40003348","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","50","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor Smtr Rddck-Saye Scrw","40003349","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","129.85","129.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L30Mm Dia4.5Mm Cort","40003350","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3287.81","3287.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L34Mm Dia4Mm No1","40003351","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","549.78","549.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L500Mm Dia4-5.5Mm Ti","40003352","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","549.78","549.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl L15Mm Dia6Mm","40003353","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","549.78","549.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L26Mm Dia4Mm No1","40003354","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X30Mm St Xl25 Rec","40003355","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L13Mm Dia3.5Mm Ant","40003356","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003357","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5516.44","5516.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne 5Cc Dbm Ptty","40003358","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia4Mm Ti","40003359","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia5.5Mm Ft","40003360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2620.8","2620.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Beam Bne Fix L120Mm Dia7Mm","40003361","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3911.25","3911.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L Md Compr Slot Lok","40003362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L45Mm Dia5.5Mm Ft","40003363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia5.5Mm Ft","40003364","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia5.5Mm Ft","40003365","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia5.5Mm Ft","40003366","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.88","320.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Xtrn Drn Csf Grad Brtt","40003367","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","548.93","548.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Od3.5Mm Ankle","40003368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Strg Tblr 7 Hl Ortholoc","40003369","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 40Mm Ortholoc","40003370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 32Mm Ortholoc","40003371","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 16Mm Ortholoc","40003372","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","870.37","870.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Sz Dia36Mm 10Deg","40003373","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1258.4","1258.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation 2.5Mm 230Mm","40003374","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","115.71","115.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X46Mm St Xl25 Recss","40003375","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X56Mm St Xl25 Recss","40003376","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","382.32","382.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail 11Mm Len 420 Mm St","40003377","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2494.71","2494.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Bio Tiss Regeneten Med","40003378","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 108Mm Cmnt Smt 3","40003379","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2718.9","2718.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Srg 23Cm 5Fr Fgrty Bil","40003380","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","218.36","218.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Titanium 2.5 Mm Ful","40003381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","55.72","55.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orthopedic Titanium Od7","40003382","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","54.52","54.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5Mm 6Mm 32Mm Ti","40003383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.16","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.3Mm Qr","40003384","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","376.19","376.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 20Mm 2.5Mm","40003385","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.38","78.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.8Mm Qr W/O Stp N","40003386","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","365.4","365.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 18Mm 2.5Mm","40003387","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","76.12","76.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation 1.4Mm 150Mm","40003388","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.25","116.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L48Mm Od4Mm Dart","40003389","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X52Mm Ank Canc Cann","40003390","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4H R Dst Fib Ank Ss","40003391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","866.25","866.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.5X5Mm Cmf Ft Self","40003392","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.39","235.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interference L25 D8 Hyd","40003393","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003394","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","140","140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 2.9Mm 34Mm Ti T","40003395","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","206","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia6.5Mm Lng","40003396","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","904.05","904.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Spinal Atlas Songer Ti","40003397","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 4F L135Cm L40Mm D5Mm","40003398","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Dia6.5Mm L32Mm","40003399","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","904.05","904.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia6.5Mm Lng","40003400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","904.05","904.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W10.2Xl104Mm Thk2.7M","40003401","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","796.32","796.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surg Strut Thk0.4Mm Sil","40003402","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","803.09","803.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L50Mm Dia6.5Mm","40003403","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","911.63","911.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X90Mm 32Mm Thrd","40003404","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Pleurx Fm Vac Btl Vlv","40003405","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","175.85","175.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stereotactic Guide Crn Traject","40003406","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2356.38","2356.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann 4.0Mmx26Mm Long Thr","40003407","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","215.66","215.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureteral 8Fr L28Cm Percu","40003408","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","313.04","313.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Tiss 15.5X16Cm 950Cc","40003409","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2126.25","2126.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2 Cp-2 Qanchr+ Pnlk","40003410","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1047.54","1047.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail  9Mm Len 375Mm St","40003411","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4408.87","4408.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg 4Mm 30Deg E Disp","40003412","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6624.19","6624.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Sur Dia2.3Mm Max","40003413","CDM","278","RC","","","","","facility","both","","","","52.5","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia5.5Mm Canc","40003414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hip 2H St 46Mm 130D","40003415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","916.98","916.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl H24-40Mm Od12Mm 6Deg","40003417","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10578.94","10578.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L55Mm Thk1.9Mm Ant","40003419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3271.18","3271.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L46Mm 2Lev Ant Cerv","40003420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrogrd Fem Nail 9Mm 320Mm","40003421","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4969.13","4969.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L8Mm Dia1.55Mm Cort","40003422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","186.65","186.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2Mm Cort Ti","40003423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","870.37","870.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Fem Condyle Lat Cart","40003424","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3471.56","3471.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H19Mm Od39Mm Id38Mm","40003425","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2256","2256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L15Mm Dia4Mm Ant","40003426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","630.42","630.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz8 L117Mm Nk L37Mm","40003427","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2828.13","2828.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 10Cc Nar Wide","40003428","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X75Mm Canc Hex","40003429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.55","452.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Pedcl 4.0Mm X 22Mm","40003430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L150Cm D0.018In","40003431","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surg 25X33Cm Polypr","40003432","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3045","3045","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 14Mm Spinal Cervical","40003433","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endo L450Cm Od0.035","40003434","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","313.95","313.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L200Mm Dia5Mm","40003435","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","2625.75","2625.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 7Fr L80Cm L80Mm D8Mm","40003436","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","2092.5","2092.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia2.5Mm Plat","40003437","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3Mm Plat","40003438","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia6.5Mm L32Mm","40003440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","904.05","904.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W10.2Xl104Mm 2.7Mm","40003441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","796.32","796.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia4Mm Plat","40003442","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L48Mm Ant Cerv 3Lev","40003443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L260Cm Dia0.035","40003444","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","37.47","37.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L34Mm Dia4.5Mm L14Mm","40003445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","751.17","751.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 7Mm 40Mm .035In 6Fr Zl","40003446","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1850.63","1850.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endo L260Cm Od0.035","40003447","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","352.8","352.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L55Mm Dia6.5Mm L32Mm","40003448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","904.05","904.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W12Xl12In Poly Mfil","40003449","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","289.8","289.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern Md 3X5In L Poly Opn","40003450","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","451.71","451.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L220Mm Dia2.8Mm","40003451","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","196","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X58Mm St Xl25 Reces","40003452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.9","480.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X80Mm Cann 32Mm","40003453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L70Mm Dia3.7Mm Cort","40003454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","333.06","333.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L55Mm Dia5.5Mm Post","40003455","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia3.5Mm","40003456","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia3.7Mm Cort","40003457","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","333.06","333.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia7Mm L32Mm","40003458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2032.5","2032.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Od43Mm Fem Hd","40003459","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3153.69","3153.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia3Mm Plat","40003460","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surg Thk0.4Mm Sil Ti","40003461","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","873.68","873.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.8Mm Q-Fix Impl","40003462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne H1.25Mm Mandible 12H","40003463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1110","1110","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 1.25Mm Matrixmndible","40003464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.5","182.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Surg L150Mm D1.25Mm","40003465","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","71.4","71.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 2Xsm 35-43Mm Sr20","40003466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113","1113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od36Mm-5Mm Offset","40003467","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221.75","1221.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X85Mm Canc 32Mm","40003468","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.65","452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 3-11Tib 16Mm","40003469","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemostat Endo Cath 7Fr L220Cm","40003470","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","3046.62","3046.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L60Mm Dia2.5Mm Disp","40003471","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","617.4","617.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia5.5Mm Ft","40003472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","711.9","711.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L8Mm Dia2Mm Ti Poly","40003473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2Mm Ti","40003474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia2Mm Ti","40003475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia1.3Mm 2Mm Lok Scr","40003476","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","646.8","646.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R 5Th Metatarsal","40003477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3008.25","3008.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L42.5Mm Dia5.5Mm Slf","40003478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.9","858.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl W15Xh7Xl12Mm 6Deg","40003479","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4114.69","4114.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Thorlum Ti","40003480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","332.64","332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X42Mm St Xl25 Recss","40003481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","509.75","509.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mm X 14Mm Ped","40003482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 3.5Mm X 65Mm Cerv Ti","40003483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","555.57","555.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5Mm X 16Mm Ped","40003484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.02","1370.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.0Mm X 26Mm Ped","40003485","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1452.22","1452.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 4.0Mm X 55Mm Cerv Ti","40003486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","555.57","555.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrd Emg Nmj Ndl Ssep Proc","40003487","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2626.36","2626.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz6 Nar Kn Cocr","40003488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196","196","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Dil 6X20Mm Ent Xpress","40003490","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2128.5","2128.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Gd 48Mm Qd-Spr Hex Hd","40003491","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","173.96","173.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X70Mm Condyle T25","40003492","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","336.13","336.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Crv 230Mm R10 4.5Mm","40003493","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1995.5","1995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 4.5X14Mm Biocmpst","40003494","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","703.5","703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L16Mm Dia3.5Mm No1","40003495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1436.4","1436.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003496","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","907.2","907.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 10X80Mm Ti","40003497","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 10X90Mm Ti","40003498","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L24Mm Dia3.5Mm","40003499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","87.5","87.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sling Gyn 7.75Cm Altis 1 Pp","40003500","CDM","278","RC","C1771","HCPCS","","","facility","both","","","","2900.12","2900.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 320Cc Dia13Cm","40003501","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Spnl Spcr 7X11X14Mm","40003502","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","958","958","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Brst Tiss 750Cc Sil","40003503","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2662.5","2662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5.5Mm Knotless","40003504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819","819","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L109Mm Dia30Mm Shth","40003505","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16250.06","16250.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub Plug Dia10Mm","40003506","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3117.19","3117.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W8.75Xl50Mm Thk1.5Mm","40003507","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2545","2545","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W8.75Xl70Mm Thk1.5Mm","40003508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L80Mm Dia7Mm L16Mm","40003509","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2731.5","2731.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.4X95Mm Fem Ti","40003510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","436.97","436.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 8H Str 104Mm 3.5Mm","40003511","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","823.84","823.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dst Dia10Mm Fem","40003512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2986.5","2986.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia8.5Mm Fem","40003513","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","186.76","186.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Fiberloop Drl Pin Ndl","40003514","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.5","1012.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp D46Mm Id28Mm Fem","40003515","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","908.77","908.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp D45Mm Id28Mm Fem","40003516","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","964.3","964.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Fem Dia10.5Mm","40003517","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","184","184","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Peri Dlys L62Cm Od5.3Mm","40003518","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","331.4","331.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Bio Tissue W1Xl6Cm","40003519","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","443.1","443.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Trach Id8.5Mm Od12.2Mm","40003520","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","141.62","141.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 16Mm Ti T8 St","40003521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","203.06","203.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5X18Mm Cort Hex Hd","40003522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.81","48.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X28Mm Cort Hex Hd","40003523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X45Mm Cort Hex Hd","40003524","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5Mm L55Mm Od3.5Mm","40003525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.38","46.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Cass 12Mm Disp For Vbr Ex","40003526","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","815.78","815.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Glen Sz4 W/ 4Peg","40003527","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1402.54","1402.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L75Mm Dia7Mm L16Mm","40003528","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2731.5","2731.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Dia2.8Mm Rcr Q-Fix","40003529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","950","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.0Mmx22Mm Pedcl","40003530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1368.67","1368.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Sut W/ 0.9Mm Mini Rep","40003531","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Esph 23Mm 18.5Fr 12.5Cm","40003532","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3479.76","3479.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 9Mm 230Cm 2.4Mm Exacto","40003533","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","36.94","36.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 6Mm X 14Mm X 12Mm","40003534","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 7Mm X 16Mm X 14Mm","40003535","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4055.62","4055.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 8Mm X 16Mm X 14Mm","40003536","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5Mm X 14Mm Pedcl","40003537","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1368.67","1368.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.0Mm X 16Mm Pedcl","40003538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1368.67","1368.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L120Mm Dia4Mm Pst Fix","40003539","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","520.8","520.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 22Mm Ti2.5","40003540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.16","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm L30Mm D5Mm","40003541","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","314.71","314.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm L30Mm D6Mm","40003542","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm L60Mm D9Mm","40003543","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathetr Ptca L80Cm L40Mm D10Mm","40003544","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathetr Ptca L80Cm L40Mm D12Mm","40003545","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathetr Ptca L80Cm L40Mm D14Mm","40003546","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm Dia0.014","40003547","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","607.24","607.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L30Mm Od6Mm","40003548","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia34Mm Thor","40003549","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","880.86","880.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L300Mm Dia12Mm Univ","40003550","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1067.92","1067.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 8C 20Cc 1X1X1Cm","40003551","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","982.09","982.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ven 14X100Mm 120Cm 0.035","40003552","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ven 16X140Mm 120Cm 0.035","40003553","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intr 12Fr L25Cm Hmstat","40003554","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","274.22","274.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio L65Cm Od5Fr Gw","40003555","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr L80Cm Gwire","40003556","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ven 14X140Mm 120Cm Gwire","40003557","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ven 16X60Mm 120Cm 0.035","40003558","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2500","2500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Surg 10Fr L20Cm Eto","40003559","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L65Cm Gwire","40003560","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Dia12Cm Wht Poly","40003561","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1088.04","1088.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr 140Cm 0.035","40003562","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","174.9","174.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Athrctmy L135Cm 2Mm","40003563","CDM","278","RC","C1724","HCPCS","","","facility","both","","","","1550.59","1550.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern 20X20Cm Macroporous","40003564","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","265.63","265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W2Xl4In Polypr Mfil","40003565","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","826.49","826.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Ves 10 Fr X 7","40003566","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","31.44","31.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L300Cm D0.014In","40003567","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathetr Ptca L80Cm L30Mm Od6Mm","40003568","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hern W5.4Xl7In Uncoat","40003569","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1795.5","1795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth L13Cm Od7Fr Hydrphl","40003570","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath 8Fr L90Cm Id2.9Mm","40003571","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","162.38","162.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca Dia23Mm Periph","40003572","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Sft-Vu N-Braid 5Fx65","40003573","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","86","86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio 5Fr 40Cm Sft-Vu","40003574","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","75.5","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Intro Dia0.018In L15Cm","40003575","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","177.5","177.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angio L80Cm Od5Fr","40003576","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding Flx Shuttle Tib","40003577","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","328.21","328.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W10Xl15Cm Flat Macro","40003578","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","628.93","628.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W10Xl14In Inguinal","40003579","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","292.95","292.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ven 16X100Mm 120Cm","40003580","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Dura W1Xl3In Regen Mtrx","40003581","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","1099.98","1099.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth 7Fr L10Cm 0.021In","40003582","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","635.25","635.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Surg 12Fr L20Cm Eto","40003583","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","160","160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 8Fr L95Cm","40003584","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","316.34","316.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca Dia20Mm Periph","40003585","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L270Mm Dia7Mm R Hum","40003586","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2031","2031","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn L46Mm Od4.5Mm 3.9Mm","40003587","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.69","335.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia38Mm Thor","40003588","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","880.86","880.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 6.5Fr L55Cm Steer","40003589","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 12Mm X 80Cm","40003590","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 12Mm X 40Mm","40003591","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 8Mm X 200Mm","40003592","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 10Mm X 80Mm","40003593","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 12Mm X 20Mm","40003594","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 9Mm X 20Mm","40003595","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 9Mm X 60Mm","40003596","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 8Mm X 60Mm","40003597","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.5Mm X120Mm","40003598","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","546","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 8Mm X 180Mm","40003599","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 3.50Mmx30Mm","40003600","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 10Mm X 20Mm","40003601","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 5.0Mm X100Mm","40003602","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 12Mm X 60Mm","40003603","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","130","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.25Mmx30Mm","40003604","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.5Mm X300Mm","40003605","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 4.0Mm X100Mm","40003606","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 5.0Mm X 80Mm","40003607","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 12Mm X 20Mm","40003608","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","130","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 6.0Mm X80Mm","40003609","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 8Mm X 150Mm","40003610","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 9Mm X 80Mm","40003611","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 3.0Mm X 60Mm","40003612","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.50Mmx30Mm","40003613","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.00Mmx30Mm","40003614","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 1.25Mmx20Mm","40003615","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 10Mm X 40Mm","40003616","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 6Mm X 40Mm","40003617","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1535.63","1535.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 8Mm X 120Mm","40003618","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 5.5Mmx100Mm","40003619","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 6Mm X 20Mm","40003620","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1535.63","1535.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 5Mm X 300Mm","40003621","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.0Mm X200Mm","40003622","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 3.75Mm X30Mm","40003623","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 9Mm X 40Mm","40003624","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.5Mm X 80Mm","40003625","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 9Mm X 80Mm","40003626","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 2.25Mmx20Mm","40003627","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 14Mm X 60Mm","40003628","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","162.5","162.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Balloon 3.75Mm X 8Mm","40003629","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blndil 4Mm X 40Mm 135Cm","40003630","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","508.93","508.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L47Mm 0Deg M 6H Poly","40003631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3493.88","3493.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ortholc L47Mm Med","40003632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3493.88","3493.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X20Mm Ft Cort","40003633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 5Mm X 220Mm 5Fr 150Cm","40003634","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 4Mm X 30Mm 4Fr 80Cm","40003635","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","483","483","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 5Mm X 150Mm 5Fr 150Cm","40003636","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 5Mm X 200Mm 5Fr 150Cm","40003637","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 1.5Mm X15Mm Mono Ptca","40003638","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 1.5Mm X 15Mm Ptca Bln","40003639","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 1.5Mm X 20Mm Ptca Bln","40003640","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 2.5Mm X 25Mm 2Fr Trns","40003641","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Bln 7Mm X 60Mm 5Fr 135Cm","40003642","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","256.45","256.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trchbr L59Cm D9Cm 120Cm","40003644","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3379.69","3379.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 4.0Mm X 38Mm Synergy","40003645","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 3.5Mm X 38Mm Synergy","40003646","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.75Mm X38Mm Synergy","40003647","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.5Mm X 8Mm Synergy","40003648","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.75Mm X 8Mm Synergy","40003649","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.5Mm X 12Mm Synergy","40003650","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.75Mm X12Mm Synergy","40003652","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 3.5Mm X 20Mm Synergy","40003653","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.5Mm X 32Mm Synergy","40003654","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 3.5Mm X 12Mm Synergy","40003655","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 2.5Mm X 24Mm Synergy","40003656","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor 3.5Mm X 32Mm Synergy","40003657","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2Mm X 13Mm Ss T6 Lck","40003658","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L320Mm Dia10Mm 130Deg","40003659","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2817","2817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia12Mm","40003660","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","148.4","148.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp Od48Mm Id28Mm Slfcntr","40003661","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","937.01","937.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx Bcmps Dist Biceps","40003662","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1821.6","1821.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L11Mm Dia2Mm Cort Ss","40003663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","188.86","188.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L28Mm Dia3.5Mm Cort","40003664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","801.36","801.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn Thk5.5Mm 4H 2.7/3.5Mm","40003665","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3066.53","3066.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia10Mm 125Deg","40003666","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3134.24","3134.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 10.35X95Mm Fen Cann","40003667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","935.09","935.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X46Mm Canc Hex Hd","40003668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Sprt Loprfl Tpr Tip","40003669","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","350.7","350.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L26Mm Dia3.5Mm Cort","40003670","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","801.36","801.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Anat Cerv Cage L","40003671","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L60Mm Dia2.5Mm For","40003672","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","595.35","595.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5Mm X 18Mm Poly","40003673","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4Mm X 26Mm Poly","40003674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.28","1334.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod 4.0Mm X 55Mm Ti Lorodtic","40003675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm X16Mm Fav Angle","40003676","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.02","1370.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4.0Mm X22Mm Fav Angle","40003677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.02","1370.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L34Mm Dia3.5Mm Brnz","40003678","CDM","278","RC","C1714","HCPCS","","","facility","both","","","","407.4","407.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L44Mm Dia4Mm Cort","40003679","CDM","278","RC","C1715","HCPCS","","","facility","both","","","","407.4","407.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L60Mm Dia4Mm Sm Dk","40003680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","655.2","655.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 350Cc D12.5Cm Gel","40003681","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L30Mm Od4Mm Cann","40003682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L30Mm Dia5.5Mm Yel","40003683","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L28Mm Od4Mm Cann","40003684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L400Mm Dia4-5.5Mm Ti","40003685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Offset Sq Neon3","40003686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Lng Offst Sq N3","40003687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Gh Fem 10-12","40003688","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.07","2049.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib 5H 103Mm Ti","40003689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882.22","882.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X26Mm Cortical","40003690","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","119.77","119.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Talar Dm Fltct 3D Sz 2","40003691","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11745.09","11745.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L315Mm Dia9Mm Tib Tn","40003692","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","366.33","366.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X16Mm Cort Hex","40003693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.5","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X24Mm Cort Hex","40003694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.5","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X32Mm Cort Hex","40003695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.5","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X65Mm Cort Hex","40003696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.5","46.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X85Mm Cort Hex","40003697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","42.75","42.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4H Crv 58.5Mm 108Mm","40003698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","850.5","850.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 12H Cr 186.5Mm 108Mm","40003699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","982","982","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L180Mm Dia2.5Mm Sht","40003700","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","229.16","229.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Cort Hex","40003701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.55","71.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Cort Hex","40003702","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Cort Hex","40003703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Cort Hex","40003704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Cort Hex","40003705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Cort Hex","40003706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X55Mm Cort Hex","40003707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","67.5","67.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L230Mm Dia2.5Mm Cali","40003708","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","228","228","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.5Mm Scaled Ao","40003709","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","394","394","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Gh Fem 7-12 H","40003710","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L145Mm Dia4.2Mm 3 Flut","40003711","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","305.84","305.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surg L20Mm Mttrsphlnl","40003712","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","744.37","744.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Ef Fem 10-11","40003713","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L30Mm Od4Mm Cann","40003714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl D3.5 4X3.5 4Mm","40003715","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1693.13","1693.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L36Mm Od4Mm Cann","40003716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L25Mm Od5.5Mm Cann","40003717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L100Mm Od4Mm Ti Ally","40003718","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occlusion Dvce 3Mm-4Mm X30Cm","40003719","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2685","2685","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl L9Mm Offset Par","40003720","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200","1200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 11.5X80Mm T","40003721","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","4869.38","4869.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L24Mm Dia5Mm No2","40003722","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia4Mm Ti Lord","40003723","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","530","530","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Spcr Acss 08Mm Dlmt","40003724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2703.75","2703.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Drl 3.5Mm X 16Mm Dl","40003725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.8","442.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm Ank Cort","40003726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L88.9Mm Dia2.5Mm Ft","40003727","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","180.2","180.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 3-5 Tib H10Mm","40003728","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tibial Xsm Trbclr Mtl","40003729","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","7372.31","7372.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Femoral Sz5 Lt Knee","40003730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","10249.31","10249.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Fem Condyle Lat Cart","40003731","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","2976.75","2976.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pack Arthscp 1.2 Disp Rap-Pac","40003732","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","640","640","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X 12Mm Dst Tib","40003733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.37","47.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X 22Mm Dst Tib","40003734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.77","47.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brush Cyto 5Fr 2Mm 120Cm Bscp","40003735","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","45.06","45.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agiliti Fbr Su 365Um","40003736","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","582","582","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 14Mm Ti Cort","40003737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","340","340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Ti L18Mm Od2.3Mm Crt","40003738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","258.64","258.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Ti L20Mm Od2.3Mm Crt","40003739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244","244","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 75Mm Ss St Va","40003740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","332","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5Mm 75Mm Ss St Va","40003741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","332","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 65Mm Ss T15 St","40003742","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","268.9","268.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 70Mm Ss T15 St","40003743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","277.17","277.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mtrx Bne 10Cc Cell Alphagrft","40003744","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","4840.91","4840.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cath 9Mm X 10Cm 120Cm","40003745","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4827.38","4827.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bne Patella W Attachment Right","40003746","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","14567.5","14567.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Speed Tendon 10.5X216Mm","40003747","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2906.25","2906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Pulm Artery 5 Fr 110 Cm","40003748","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","193","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio Diag 7Fr 100Cm","40003749","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","225","225","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 4Fr L125Cm 0.038In","40003750","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","149.85","149.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Cervical Stndrd 22 Mm","40003751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1209","1209","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L45Mm Dia3.5Mm","40003752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","378.11","378.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4H Lckng 2.7/3.5Mm S","40003753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4219.16","4219.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L9Mm Rt Neon3","40003754","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink 5.5Mm Rod S, 53-68Mm","40003755","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7021.88","7021.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink 5.5Mm Rod Xs 41-56Mm","40003756","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7021.88","7021.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslnk 5.5Mm Rod Xxs 35-43Mm","40003757","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7021.88","7021.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L100Mm Od4Mm Ti","40003758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25Mm Od5.5Mm Can","40003759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spn 4X30Mm Pstr Polyax Ti","40003760","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.45","1146.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L300Mm Dia5.5Mm Pstr","40003761","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Cervical 4Mm X 14Mm","40003762","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.85","500.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Antr Crvcl 4.0Mm Dia 18Mm","40003763","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L110Mm Dia5.5Mm Postr","40003764","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.56","480.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Lrdtc Expndbl 10X10X25Mm20","40003765","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","9043.13","9043.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spn 5X30Mm Pstr Polyax Ti","40003766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.45","1146.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl 5.5X30Mm Polyax Ti","40003767","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Fibertape W2Mm Cerclage","40003768","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Ortho Dia18Mm Spiked","40003769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Acss 16Mm-14Mm-8Mm 13","40003770","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3244.5","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5Mm Dia 36Mm Poly","40003771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1496.25","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia5.5Mm Ti","40003772","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Pedicle Mis Olympic","40003773","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","374.85","374.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Gyno W8Xl12Cm Allogrft","40003774","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4019.32","4019.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector T/S 3.5/4.0-3.5/4.0","40003775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2128.62","2128.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 9X22X9.5-14Mm 10D","40003776","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11130","11130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X45Mm Posterior","40003777","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2003.4","2003.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 4.5Mm 2 36In","40003778","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","928.24","928.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia9.25Mm Dst","40003779","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","184.3","184.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Driver Power Disposable","40003780","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia3.2Mm Ti","40003781","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","637.98","637.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia3.2Mm Ti","40003782","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","15.2","15.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spn L28Mm Dia4.5Mm Poly","40003783","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1858.73","1858.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Extended Perl","40003784","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","313.87","313.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Hex Perla","40003785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","313.87","313.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Golden Gate  Polyaxial","40003786","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Ts 15X13X6Mm","40003787","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibertape Cerclage W/O Needle","40003788","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","950","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tigertape Cerclage W/O Needle","40003790","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","950","950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 1.6X4Mm 16-Nf-004","40003791","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","166.6","166.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 1.6X5Mm 16-Nf-005","40003792","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154","154","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infinity Everlast Sz 5 6Mm","40003793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2503.75","2503.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement V-Steady 20Gm","40003794","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3244.5","3244.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mixer Cement V-Steady","40003795","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","324.45","324.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotid L30Mm D8Mm","40003796","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3543.75","3543.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eluvia 6Mm X 60Mm X130Cm","40003797","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3142.13","3142.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 7.0Mm X59Mm 135Cm","40003798","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Syst 5.0Mmx80Mm 6Frx120Cm","40003799","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 6.0Mmx29Mm 135Cm","40003800","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Syst 5.0Mmx40Mm 6Frx120Cm","40003801","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Sys 5.5Mmx150Mm 6Frx120Cm","40003802","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 6Mm X80Mm 135Cm","40003803","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.75Mm X 28Mm Synergy Xd","40003804","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003805","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2512.5","2512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annuloplasty Ring 26Mm Mitral","40003806","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annuloplasty Ring 38Mm Mitral","40003807","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annuloplasty Ring 34Mm Mitral","40003808","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annuloplasty Ring 36Mm Mitral","40003809","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annuloplasty Ring 28Mm Mitral","40003810","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 9Mm X 5Cm 120Cm","40003811","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4389","4389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protector 3.5Mm X 40Mm Axo Nrv","40003812","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2512.5","2512.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admiral Av 7Frx9Mmx60Mmx80Cm","40003813","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admiral Av 7Fr X9Mmx80Mm X80Cm","40003814","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2092.5","2092.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admiral Av 7Fr X7Mmx40Mm X80Cm","40003816","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.00Mmx30Mm 5Fx140Cm","40003817","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Femoral Size 5 Thk10Mm","40003818","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2392.5","2392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Femoral Size 5 Thk5Mm","40003819","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2392.5","2392.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr Convey Guiding Al2","40003820","CDM","270","RC","C1887","HCPCS","","","facility","both","","","","137.5","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 7Mm X 60 Mm 135 Cm","40003821","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Indigo Separator 12 System","40003822","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","3063.38","3063.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun Cement V-Hp","40003823","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","758.52","758.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screws Polyaxial 5 X 32","40003824","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1502.55","1502.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixation Dia1.1Mm Troca","40003825","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","106","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L58Mm Dia3.5Mm","40003826","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","408.24","408.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14Mm Dia4Mm Ti","40003827","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","408.24","408.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 10 Hole Ortholoc","40003828","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1533.73","1533.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X50Mm Xl25 Lcking","40003829","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L120Mm Dia3.5Mm Ti","40003830","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","587.24","587.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 5X40Mm Xl25 Locking","40003831","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 10Hl 232Mm 3.5Mm Scrw","40003832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2453.4","2453.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40003833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2595.89","2595.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L40Mm Dia3.5Mm Ti","40003834","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L35Mm Dia3.5Mm Cert","40003835","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","616.6","616.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L140Mm Od5.4Mm Pstr","40003836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W18Xh8Xl16Mm 10D","40003837","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1704.75","1704.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sys Lfrt Neuro 112?98.3Mm","40003838","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2448","2448","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infnt Adpts Flatcut Tl Dom Sz5","40003839","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","8400","8400","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vascular 12 Mm Dia 400Mm","40003840","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1032.49","1032.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prebent Ti Rod Diam 3.5 L40Mm","40003841","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","378.11","378.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Straight Ti Rod Diam 3.5 L35Mm","40003842","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","378.11","378.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conn Crs Spnl 40Mm Invictus Ct","40003843","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","975","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Spinal 2.3Mm X 12Mm","40003845","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","213.92","213.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tib Sz F Thk9Mm R Med","40003846","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1829.77","1829.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Dstl Fem 9.25Mm Di","40003847","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","187.46","187.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L330Mm Dia9Mm Tibial","40003848","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2495.28","2495.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap 0Mm Ti Xl25 Stardrive","40003849","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","469.01","469.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Sz E","40003850","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1919.93","1919.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl Sm W15Xh7Mm Dia12Mm","40003851","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coracoclavicular Ligament","40003852","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2270.52","2270.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Driver 1.5Mm Hex Locking","40003853","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","655.2","655.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L120Mm Dia5.4Mm","40003854","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn L34Mm Dia4.5Mm Dia8Mm","40003855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","93.28","93.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 3Hl 62Mm 130Deg 4.5Mm","40003856","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","986.94","986.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X150Mm Crtcl Hex","40003857","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","161.29","161.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia10Mm Tib Tn","40003858","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2448.95","2448.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn 5X44Mm Xl25 Lcking Ti","40003859","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2522.42","2522.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Crvcl 4Mm X 16Mm","40003860","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","374.37","374.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal 7D 7Mmx16Mmx14Mm","40003861","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Spnl Intrfxtd 12Mm","40003862","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","400.68","400.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 5.5Mm X 30Mm","40003863","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1452.22","1452.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Lrdtc Ti 4.0Mmx100Mm","40003864","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","555.57","555.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun Cement V-Hp","40003865","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsc Artificial H5Mm 17X19Mm Ti","40003866","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7087.5","7087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Humeral 42Mm Od 24Mm","40003867","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2391.36","2391.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Single Ended 2.7Mm Dia","40003868","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1539.19","1539.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 1/3 Tblr 81X9X1Mm Ss","40003869","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","325.75","325.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5Mm 6Mm 20Mm Ss","40003870","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.08","47.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5Mm 2.9Mm 16Mm Ss","40003871","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","214.59","214.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hemo Adult 14.5Fr L40Cm","40003872","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","396","396","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L22Cm Dia10Mm Ti","40003873","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","21062.5","21062.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn L80Mm Dia 5Mm Dynanail","40003874","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","982.5","982.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn 5Mm Dia 30Mm Dynanail","40003875","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","847.5","847.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn L22.5Mm Dia5Mm Crtcl","40003876","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","847.5","847.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia12Mm St Lng Flx","40003877","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1884.28","1884.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bn 2.7X14Mm Crtcl Locking","40003878","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230","230","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 20Mm Ortholoc Ft","40003880","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix Sm D1.4Mm Ft Ortholoc","40003881","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","236.29","236.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 13Mm Zevo Ti Spne","40003882","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","510.14","510.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bp Gry 43Mm 28Mm Slfcntr","40003883","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fx 2X150Mm Trcr Pt Ss","40003884","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","162.22","162.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 10Mm 2.5Mm","40003885","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.04","82.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 24Mm Ss Ped T8","40003886","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.04","82.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 30Mm 2.5Mm","40003887","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.4","77.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Mis Long","40003888","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","207.2","207.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 22Mm Ss 2.5Mm","40003889","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.38","69.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Ss 1/3 Thrd L68Mm Od","40003890","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.4","365.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Ss 1/3 Thrd L64Mm Od","40003891","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.4","365.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4.0X40Mm Shockwave S4 Ivl","40003892","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","2750","2750","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uc Graftmaster Ii Set","40003893","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Safeop Emg/ Ssep Ndl Electrd","40003894","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2157.03","2157.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.5Mm X 16Mm Synergy Xd","40003895","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.75Mm X 24Mm Synergy Xd","40003896","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mm X 32Mm Synergy Xd","40003897","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eluvia 6Mmx80Mmx130Cm","40003898","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3012.19","3012.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw L30Mm Dia10Mm Shth L30Mm","40003899","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","945","945","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4.0Mm X 30Mm Pantera","40003900","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.5Mm X 16Mm Synergy Xd","40003901","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.5Mm X 28Mm Synergy Xd","40003902","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 5.5Mm X 120Mm 6Frx120Cm","40003903","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2065.5","2065.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 6Mmx 40Mmx135Cm","40003904","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 10.0Mmx39Mm 135Cm","40003905","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Grft 13Mm X 10Cm X 120Cm","40003906","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4827.38","4827.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.0Mm X 8Mm Synergy Xd","40003907","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 6.0Mmx120Mm 6Frx120Cm","40003908","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eluvia 7Mmx60Mmx130Cm","40003909","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3405.94","3405.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L40Mm Dia5Mm 6Fr L120Cm","40003910","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mm X 20Mm Synergy Xd","40003911","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.75Mm X 32Mm Synergy Xd","40003912","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 9.0Mmx59Mm 135Cm","40003913","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L80Mm Dia5Mm 6Fr L120Cm","40003914","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 5Mm X 40Mm 135Cm","40003915","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.0Mm X 16Mm Synergy Xd","40003916","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mm X 24Mm Synergy Xd","40003917","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 5.0Mm X 100Mm 6Frx120Cm","40003918","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent System 5Mm X 60Mm 135Cm","40003919","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","900","900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tibial Sz 6-9Cd Lt 14Mm","40003920","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.01","2172.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Cerclage L750Mm Dia1.7Mm","40003921","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","907.96","907.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microcoil L7Cm D10Mm 0.035In","40003922","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal H14X9Mm 30X39Mm","40003923","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5775","5775","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X72Mm Canc Cann","40003924","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.4","365.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cover Bur H Dia15Mm 6 H Blu Ti","40003925","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","336.57","336.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Dia13Mm 6.5 7.3Mm","40003926","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","57.5","57.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Soft Tissue W10Cm Thk1Mm","40003927","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Ank Infin 6Mm Sz 2+","40003928","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3877.18","3877.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath L25Cm L2.5Cm 0.035In","40003929","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","572.88","572.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eprsth 35Mm 14.5Mm 14Cm","40003930","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","14555.63","14555.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.25Mmx15Mm 5F 140Cm","40003931","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 4.00Mmx18Mm 5F 140Cm","40003932","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.75Mmx26Mm 5F 140Cm","40003933","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.25Mm 38Mm 2.7F .0357In","40003934","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eprsth 14.5Mm X 10Cm Contralat","40003935","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 4.00Mmx30Mm 5F 140Cm","40003936","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx15Mm 5F 140Cm","40003937","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.00Mmx20Mm 5F 140Cm","40003938","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 5.00Mm 26Mm 3.2F 0.042In","40003939","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx35Mm 5F 140Cm","40003940","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.25Mmx9Mm 5Fr 140Cm","40003941","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 4.00Mmx15Mm 5F 140Cm","40003942","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx20Mm 5F 140Cm","40003943","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 5.00Mm 12Mm 3.2F 0.042In","40003944","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.75Mmx13Mm 5F 140Cm","40003945","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx18Mm 5F 140Cm","40003946","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 4.00Mmx22Mm 5F 140Cm","40003947","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eprsth 27Mm X 12Cm Contralater","40003948","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5945.63","5945.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.00Mmx9Mm 5Fr 140Cm","40003949","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.25Mmx18Mm 5F 140Cm","40003950","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 4.00Mmx20Mm 5F 140Cm","40003951","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 100Cm Aspiration 12+Tubin","40003952","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","8938.13","8938.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eprsth 36Mm Dia X 4.5Cm Len","40003953","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.00Mmx15Mm 5F 140Cm","40003954","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.75Mmx20Mm 5F 140Cm","40003955","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.25Mmx13Mm 5F 140Cm","40003956","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.00Mmx18Mm 5F 140Cm","40003957","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx22Mm 5F 140Cm","40003958","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 3.50Mmx9Mm 5Fr 140Cm","40003959","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.50Mmx18Mm 5F 140Cm","40003960","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 2.75Mmx22Mm 5F 140Cm","40003961","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Olecranon Prox L 2 H","40003962","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1488.46","1488.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L109Mm Dia32Mm Aaa","40003963","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22896.71","22896.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 5Cc Dbm Ptty Jr","40003964","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","996","996","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dil L110Cm Blln L3Cm","40003965","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","555.11","555.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort 25Mm Pericard","40003966","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort 27Mm Pericard","40003967","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort 29Mm Pericard","40003968","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort 31Mm Pericard","40003969","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort 33Mm Pericard","40003970","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Del L180Cm Dia2.5Mm","40003971","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","452.61","452.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L113Mm Dia34Mm Aaa","40003972","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","23583","23583","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L74Mm Dia11Mm Iliac","40003973","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5242.13","5242.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L56Mm Dia13Mm Iliac","40003974","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5242.13","5242.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura W2Xl2In Ult Pure","40003975","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","1102.82","1102.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura W4Xl5In Ult Pure","40003976","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","2743.8","2743.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Menis Rep 12Deg Ndl","40003977","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1056.78","1056.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Menis Rep 24Deg Ndl","40003978","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1041.39","1041.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autotrns Aspr Anticoag Cll Svr","40003979","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","996.33","996.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34Mm Dia3.5Mm Cort","40003980","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22Mm Dia4Mm Grn Ti","40003981","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L Short Hk For Ank","40003982","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.4","77.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ptca L80Cm Blln L30Mm","40003983","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.04","82.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6X45Mm Pedcl St","40003984","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.4","77.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire 500Mm","40003985","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","200","200","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 9X24X9.5-14Mm","40003986","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","70.77","70.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allowash Xg Sterilized Allogft","40003987","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.4","365.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therasleeve With 120 Seeds","40003988","CDM","278","RC","C2640","HCPCS","","","facility","both","","","","386.22","386.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therasleeve With 100 Seeds","40003989","CDM","278","RC","C2640","HCPCS","","","facility","both","","","","977.38","977.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun Bone Cem Del Sz 2 W/ Bone","40003990","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1577.77","1577.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal L 40-56Mm","40003991","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22896.71","22896.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L27Mm Thk1.9Mm Ant","40003992","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","555.11","555.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Ext Fix 5Deg R Ss","40003993","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X86Mm St Xl25","40003994","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10851.75","10851.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X78Mm St Xl25","40003995","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10851.75","10851.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X72Mm St Xl25","40003996","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10237.5","10237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.5Mm Rev Shldr Sys","40003998","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","426.99","426.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidepin Orth Dia2.5Mm Glen","40003999","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","23583","23583","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L15Mm Dia6Mm Cann","40004000","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5242.13","5242.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Shldr +9Mm For Tm Rev","40004001","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5242.13","5242.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Shldr +9Mm For Tm Rev","40004002","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1026","1026","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphere Glen Mtl/Polymer Cem","40004003","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1026","1026","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L24Mm Dia4.5Mm Canc","40004004","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150.7","150.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L27Mm Dia4.5Mm Canc","40004005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150.7","150.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia4.5Mm Shldr","40004006","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150.7","150.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum L122Mm Dia8Mm Shldr","40004007","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4765.03","4765.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plug Bne Sm 12Mm For 8-10Mm Im","40004008","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.46","467.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tib Sz2 Tot Ank Sys Bioform 3D","40004009","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","10748.06","10748.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L390Mm Dia9Mm Tib St","40004010","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2495.28","2495.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Shft L Cs3 St","40004011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2001.51","2001.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Cd Fem 6-9","40004012","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L10Mm Dia2Mm Cort Ti","40004013","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","970.2","970.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L225Mm Dia4.5Mm Ss Sgl","40004014","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","167.1","167.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tib Sz D Thk10Mm R Med","40004015","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infinity Everlast Sz 2 6Mm","40004016","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3764.25","3764.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L55Mm Dia6.5Mm","40004017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L50Mm Od5.5Mm Ticp","40004018","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L45Mm Od5.5Mm Ticp","40004019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L55Mm Dia6.5Mm Cort","40004020","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia3.5Mm Post","40004021","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crss Conn Rod To Rod 3.5Mm45Mm","40004022","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1016.16","1016.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl 4Mm X 16Mm Insignia","40004023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 15D 8Mmx16Mmx14Mm","40004024","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3937.5","3937.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Temp Fix Spnl Hexalobe","40004025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.4","185.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Talar Dome Flatcut 3D","40004026","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","12087.18","12087.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Ank Xlpe Infin Everlast","40004027","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3990.11","3990.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreas L4Cm Od5Fr","40004028","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","169.18","169.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L55Mm Std Bilat Ant","40004029","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1953","1953","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cranial Low Profile 4Mm","40004030","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","609","609","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Nephstmy L15Cm Blln","40004031","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","679.23","679.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Novostitch Pro Sz 0","40004032","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1042.5","1042.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L5Cm Dia7Mm Cath","40004033","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4554.38","4554.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L5Cm Dia9Mm","40004034","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4389","4389","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 8 H Str Tblr","40004035","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206","1206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X18Mm Ank Canc Ft","40004036","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","522.38","522.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Ank Cort Ft","40004037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","522.38","522.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X28Mm Compr Cann","40004038","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","711.92","711.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Compr Cann","40004039","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trachbronch L22Cm Dia6Cm","40004040","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3300.94","3300.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum L130Mm Dia10Mm Shldr","40004041","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","6922.79","6922.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Hum Dia36Mm 7Deg +0Mm","40004042","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1456.88","1456.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X62Mm St Xl25","40004043","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L375Mm Dia10Mm Tib St","40004044","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2354.04","2354.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 5 H 49Mm Ss Mod Mini","40004045","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","780.47","780.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.25X150Mm Trcr Pt Ss","40004046","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","18.68","18.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.6X150Mm Trcr Pt Ss","40004047","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","18.79","18.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L6In Dia0.062In Dbl","40004048","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","18","18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 92Mm Ss 2.7Mm Scr 4H","40004049","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1123.5","1123.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn L72Mm 4H Lcp Combi","40004050","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1105.5","1105.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 26Mm Ss Ped T8","40004051","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","80.21","80.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 46Mm Ss Ped T8","40004052","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.67","75.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 5Mm 48Mm 2.5Mm","40004053","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.67","75.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 16Mm Ss Ped T8","40004054","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.91","78.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 40Mm Ss Ped T8","40004055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.67","75.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7Mm 44Mm Ss T8 Cort","40004056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.67","75.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wre Fix L4In Dia0.035In Dbl","40004057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","19.88","19.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Thulium Lp 365","40004058","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","852.6","852.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut 25Deg L Crv Nit Wre","40004059","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5.5Mm 2 Sq Ft","40004060","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","724.5","724.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Olecranon L 6 H","40004061","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1939.08","1939.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Bx Dia2.8Mm Disp Rad","40004062","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","45.04","45.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Thor 24Fr L20In Sil 6","40004063","CDM","278","RC","","","","","facility","both","","","","53.22","53.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X22Mm Compr Cann","40004064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","743.48","743.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload Stapler L80Mm Blu Ti","40004065","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","141.1","141.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Opn Sur Stpl 3.8Mm Ti","40004066","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","234.67","234.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L24Mm Dia3Mm Cort Ft","40004067","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","266.7","266.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L20Mm Dia8Mm Ant","40004068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Pmp Gwire 0.025In W/ Ctrl","40004069","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","35000","35000","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Tot Ank Sz 5 Lng Tib 3D","40004070","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11392.94","11392.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lp 3.0X12Mm Cort Mtp Ti","40004071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X12Mm Ti Val","40004072","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maxforce Mtp Plt Std 0-0 L","40004073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3142.13","3142.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lp 3.0X24Mm Cort Mtp Ti","40004074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth Dia0.045In","40004075","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","170","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia4Mm Ss Cann","40004076","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","822.15","822.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L24In Cann Thrd","40004077","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","212","212","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L44Mm Dia4Mm Cort Ti","40004078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","984","984","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 6Fr L55Cm Dia2.2Mm","40004079","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 7Fr L55Cm Gwire","40004080","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L90Mm Dia5.5Mm Yel Ti","40004081","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 9X24X7-10.5Mm 3Deg","40004082","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8203.13","8203.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Brst Tiss 600Cc Sil","40004083","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2662.5","2662.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty Sz3 L15Mm Syr 30Ml","40004084","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","5112.19","5112.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Cerv 72Mm 4Lev 10H","40004085","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Otlif 09Mmx25Mmx09.5 14.0Mmx0","40004086","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8203.13","8203.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40Mm Dia4.5Mm Ti","40004087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2181","2181","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Polyproylene Coloplast","40004088","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2725.53","2725.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ulna X-Artc Prox L 8","40004089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1883.7","1883.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 4 L105Mm Nk L35Mm","40004090","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2997.15","2997.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 125Mm 2.7Mm 3 Flt Qc","40004091","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","160.68","160.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcp Osteo 60Mm 90Deg/15M","40004092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","911.36","911.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applier In Clp Lg 33Cm Ti Pstl","40004093","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","180.65","180.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X12Mm Cort Ft","40004094","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.76","116.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X14Mm Cort Ft","40004095","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","117.09","117.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X58Mm Stardrv","40004096","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","206","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7 Va Lcp","40004097","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1240.5","1240.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od42Mm Id28Mm Fem","40004098","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1147.5","1147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 6 L111Mm Nk L35Mm","40004099","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2912.32","2912.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia3.2Mm Sht","40004101","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","636.3","636.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L30Mm Dia3.2Mm Lng","40004102","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","636.3","636.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fixatn Dia0.9Mm Magenta","40004103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","106","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia10Mm Nk","40004104","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3134.24","3134.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia9Mm Nk","40004105","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2622.85","2622.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl L55-80Mm Polyax","40004106","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2700","2700","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 3 Hip Std Offset","40004107","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3241.88","3241.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Femoral Od47Mm Id28Mm Hip","40004108","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","909.72","909.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W16.5Xl64Mm Thk2Mm","40004109","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.75","1338.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia4.5Mm Hd","40004110","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","93.28","93.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia4.5Mm Hd","40004111","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","93.28","93.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Med Dst L 6 H St","40004112","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2045.92","2045.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L170Mm Dia3.2Mm 1.7Mm","40004113","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","387.32","387.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Crvicl 2 Level 36Mm","40004114","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2139.3","2139.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Kl 1.8 Fibertak","40004115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","934.92","934.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L390Mm Dia9Mm Tib St","40004116","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2353.5","2353.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X85Mm Canc Hex","40004117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm Nk","40004118","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2986.02","2986.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 7 R Nar Cr","40004119","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia3.5Mm Hd","40004120","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","533.4","533.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 34X26X13Mm 15Deg","40004121","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5906.25","5906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Alif Ti 15 Deg 13Mm","40004122","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X34Mm Cort Hex","40004123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.92","49.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mic 2.8X22Mm Calcnl","40004124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","899.33","899.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X32Mm Compr Cann","40004125","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.6","726.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X40Mm Compr Cann","40004126","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.13","741.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Surg High Pwr Holmium","40004127","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1453.72","1453.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 19X29Mm 9Mm 0Deg","40004128","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4134.38","4134.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X90Mm Canc Hex","40004129","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl 8Mm Std Ti-6Al-4V","40004130","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Self-Drilling 2.1 5Mm","40004131","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","137.5","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Lord 25Mm Fh9 Ti","40004132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4382.44","4382.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X45Mm Cann","40004133","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Linesider Set Scr T25 5.5 6.0","40004134","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Rod Mis 5.5Mm 45Mm Crv","40004135","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 5.5X50Mm Crv Ti","40004136","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.4Mm Kirschner Wire Blunt Tip","40004137","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapl Bne Fix L12Mm Brdg W12Mm","40004138","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2704.5","2704.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz C R Fix Np","40004139","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1191","1191","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tib Sz Cd Thk10Mm R","40004140","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1897.88","1897.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix L14Mm Dia2Mm Volar","40004141","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","186.56","186.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cann Polyaxial Screw 7.5X50","40004142","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Ti 14Mmx12Mmx6Mm","40004143","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5118.75","5118.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Ti 14Mmx12Mmx7Mm","40004144","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5118.75","5118.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4X14Mm Slf Drl Ti","40004145","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4X16Mm Slf Drl Ti","40004146","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.38","270.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4X18Mm Slf Drl Ti","40004147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","274.31","274.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W16.5Xl60Mm Thk2Mm","40004148","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1378.92","1378.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Thrd Od2.5Mm Ant","40004149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","321.3","321.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L330Mm Dia10Mm Tib Tn","40004150","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2494.71","2494.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.7X30Mm Compr Hdlss","40004151","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","908.77","908.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.7X40Mm Compr Hdlss","40004152","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","908.77","908.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.7X50Mm Compr Hdlss","40004153","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","963.3","963.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ank Jt Ti Od9Mm Subtlr","40004154","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4287.84","4287.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L35Mm Dia6.5Mm","40004155","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L48Mm Thk1.9Mm Ant","40004156","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3085.43","3085.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm Dia3Mm L10Mm","40004157","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","852.56","852.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload Stplr 90Mmx3.5Mm Ta Ti","40004158","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","98.81","98.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Endoscp Plntr Fasctmy","40004159","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1621.62","1621.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss L155Mm Dia4-5Mm","40004160","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2093.18","2093.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 10.35X100Mm Fen Cann","40004161","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","902.85","902.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 8 L139Mm Nk L38Mm","40004162","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","2550","2550","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prox L 6 H St Sm","40004163","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","2131.5","2131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Fem Dia15Mm Dst","40004164","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","184.3","184.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brush Cyto","40004167","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","193.33","193.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Aspr 21X15Ga L15Mm L115Cm","40004168","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","156.53","156.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 550Cc D13.6Cm","40004169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1192.5","1192.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X14Mm Cort T8","40004170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","119.75","119.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Lng 2X2 H T Fus 61Mm","40004171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1106.84","1106.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Lng 3X7 H T Fus 92Mm","40004172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1345.7","1345.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Achilles Tendon Ps 10Mm Atp102","40004173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4068.75","4068.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Acss W14Xh7Xl12Mm","40004174","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3150","3150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L4In Dia2Mm Fast Guid","40004175","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","207.76","207.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Antimic 3.5 X 4","40004176","CDM","270","RC","A6196","HCPCS","","","facility","both","","","","52.12","52.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X28Mm St Xl25 Ti","40004177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","591.86","591.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth 0Mm For Tn Adv Sys","40004178","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","448.81","448.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth For 3.5/4Mm Screw","40004179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","98","98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne L26Mm Dia3.5Mm Calcnl","40004180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","801.36","801.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L26Mm Dia3.5Mm Ti","40004181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338.31","338.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia3.5Mm Ti","40004182","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338.31","338.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L25Mm Dia3.3Mm","40004183","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","193.2","193.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impella Rp Smartassist Pump Kt","40004184","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","31250","31250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L25Mm Dia4Mm Trident","40004185","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","193.2","193.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X36Mm St Xl25 Reces","40004186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","627.37","627.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4H 90Mm Ss 2.7 3.5Mm","40004187","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","886.32","886.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X28Mm Cort Hex Dr","40004188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","79.15","79.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L35Mm Dia7.5Mm Blu","40004189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L70Mm Dia8Mm Polyax","40004190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L50Mm Dia7.5Mm","40004191","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 7Mm Full For Acss","40004192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2782.5","2782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L55Mm Dia7.5Mm","40004193","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2263.5","2263.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Short Straight 2 Holes","40004194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Low Profile 1.4 3Mm","40004195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.5","196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L70Mm Calcnl 2.7Mm","40004196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1590.36","1590.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32Mm Xl25 Recess","40004197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","522.66","522.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X28Mm Xl25 Recess","40004198","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","519.64","519.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X24Mm Cort Hex","40004199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.67","74.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X32Mm Cort Hex","40004200","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","74.67","74.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm D2Mm L4Mm Ti","40004201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","807.39","807.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L38Mm D3.5Mm L15Mm","40004202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia3Mm Thrd","40004203","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.82","102.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia3Mm Thrd","40004204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Implnt 450Cc 13.2Cm 4.5Cm","40004205","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1732.5","1732.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Alg 3.5X10In Tan","40004206","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","72.42","72.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole Plate Small","40004208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","526.58","526.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole Plate Large","40004209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole Plate Shunt Large","40004210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819","819","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 1.4X4Mm Ult Lo Pro Grn","40004211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.5","196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.4 5Mm Low Profile Screw","40004212","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.5","196.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"2 Holes Straight Plate Long","40004213","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","220","220","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd L25.4Mm Dia3Mm","40004214","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","286.19","286.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L12Cm Hd L3.8Mm D3.5Mm","40004215","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","73.44","73.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L14Cm Hd L3.8Mm Dia3Mm","40004216","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","297.19","297.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L7Cm Hd L6.4Mm D1.1Mm","40004217","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","207.54","207.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd L11.4Mm Dia9Mm","40004218","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","283.02","283.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd L3.8Mm Dia3Mm","40004219","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","293.54","293.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L10Cm Hd Dia2Mm Dmnd","40004220","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","279.82","279.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd Dia6Mm Ball","40004221","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","302.91","302.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd L9.4Mm D7.5Mm","40004222","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","283.02","283.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd L17.9Mm D3.2Mm","40004223","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","399.86","399.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd Dia4Mm Ball","40004224","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","302.62","302.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L10Cm Hd Dia4Mm Dmnd X","40004225","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","325.26","325.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Twst L7Cm Hd Dia1.5Mm","40004226","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","226.23","226.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perforator Sur Od14Mm Id11Mm","40004227","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","362.88","362.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Att Mr8 9Cm Metal Cutter 3.2Mm","40004228","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1732.01","1732.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrench Motr Legend Midas Rex","40004229","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","189.9","189.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Tot Ank Sz 3 Lng Tib 3D","40004230","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","10963.02","10963.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Ank Xlpe Infn 8Mm Sz 2+","40004231","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3764.25","3764.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L440Mm Dia10Mm Nk","40004232","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4178.98","4178.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L120Mm Od5.5Mm Ticp","40004233","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut L19.1Mm Dia4.75Mm","40004234","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","975.2","975.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"1Cc Syr Of Bg Ptty Bioactive","40004235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal Xl 5.5/6Mm Va","40004236","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1693.13","1693.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicle 7.5X40Mm","40004237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicle 7.5X45Mm","40004238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Lat Lumbar 5X30Mm","40004239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 11Mm 15Deg Half","40004240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4593.75","4593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cerv Spcr Ti 7 Deg 6Mmx16Mmx14","40004241","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4173.75","4173.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Cerv Ti 3.5Mmx30Mm","40004242","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal 34X26X11Mm 15Deg","40004243","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5906.25","5906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L80Mm Dia9Mm Il","40004244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.19","1878.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L90Mm Dia9Mm Il","40004245","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Grft Spnl Alif 8.5Mmx25Mm","40004246","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1928.28","1928.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alif Sa Spacer 6 X 34 X 24 Mm","40004247","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8347.5","8347.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L60Mm Dia5.5Mm Ti","40004248","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fav Ang 9.5Mmx80Mm","40004249","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3188.88","3188.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fav Ang 9.5Mmx90Mm","40004250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3068.55","3068.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Si Core 7.5Mm X 40Mm","40004251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3188.88","3188.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Para Cls To Opn","40004252","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia7.5Mm Blu","40004253","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1216.35","1216.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 5Cc Ca Sulfate","40004254","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4135.69","4135.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub Regen Inj 2Ml","40004255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1992.38","1992.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Canc Pro-Pk","40004256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.26","364.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Prost Spaceoar Rctm Ant","40004257","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3928.31","3928.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Dia32Mm Thk8.5Mm","40004258","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","863.1","863.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.6X14Mm Va Slf Drl","40004259","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.6X16Mm Va Slf Drl","40004260","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Dstrctr L14Mm Cerv Artfcl","40004261","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W14Xh7Mm Ant Cerv","40004262","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4945.5","4945.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl W8Xh7Xl14Mm 7Deg","40004263","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2665.5","2665.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X30Mm Va Ft Lok","40004264","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.44","237.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Prof For 4.7Mm Scr","40004265","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Driver Sur L8Mm Dia1.5Mm Mic","40004266","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","590.1","590.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix Attch For Md Mult","40004267","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","535.5","535.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix Md Slf Hld Clp","40004268","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","816.94","816.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L240Mm Dia8Mm C","40004269","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Int Fix W/ Biocomposite","40004270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2782.5","2782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W14Xl24Mm Thk0.3Mm","40004271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","970","970","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prox L 6H L Bend","40004272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2316","2316","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Prof L20Mm Dia1.9Mm","40004273","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","865.2","865.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hook Spnl Dia5.5Mm 15Deg L Ang","40004274","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1280.48","1280.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hndl Awl For Ant Cerv Plating","40004275","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2086.88","2086.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L80Mm Dia8.5Mm Ti","40004276","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Scr Spnl Od8.5Mm Ti","40004277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","577.5","577.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Grft Sub L 8Cc 12Mg","40004278","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","7980","7980","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Med Dst L 8 H","40004279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl W39Xh14X6.7Mm D30Mm","40004280","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5775","5775","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spnl M 28X34.5Mm 5Deg","40004281","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7016.08","7016.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spnl M 28X34.5Mm 6Deg","40004282","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7016.08","7016.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Sm W11Xl72Mm","40004283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","562.15","562.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X56Mm Xl25 Recess","40004284","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 2.5X6Mm","40004285","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60Mm Xl25 Recess","40004286","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.77","534.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tib Sz B L Med Knee","40004287","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem M Part Knee Twin","40004288","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tib M Thk4Mm L Menis","40004289","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl H24-40Mm Dia14Mm","40004290","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","11107.89","11107.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl H16-25Mm Dia14Mm","40004291","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","11107.89","11107.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Cass Dia14Mm Disp","40004292","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","815.77","815.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 2.1X5Mm Optimal","40004293","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia2Mm Thrd","40004294","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Dia2Mm Thrd","40004295","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L35Mm Dia5Mm Ti","40004296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","786.24","786.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty Sz 3 Ballon L15Mm","40004297","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","4511.83","4511.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Gyn W8Xl12Cm Derm","40004298","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","5237.17","5237.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum 7H St Lng 127Mm","40004299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1803.38","1803.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fixation L200Mm Dia4Mm Cnt","40004300","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","616.81","616.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fibula 5H 99Mm Ti","40004301","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882","882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L38Mm Dia4Mm Sm Ti","40004302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","655.2","655.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40Mm Dia4Mm Sm Ti","40004303","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","719","719","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Hd Dia5Mm Ball","40004304","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","8299.2","8299.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 440Cc Dia13.1Cm","40004305","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 500Cc Dia13.2Cm","40004306","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","5775","5775","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 550Cc Dia13.6Cm","40004307","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","6883.7","6883.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 650Cc Dia13.5Cm","40004308","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","6618.94","6618.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl 10Mm Std Ti-6Al-4V","40004309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","562.15","562.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 2.1X6Mm Optimal","40004310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 2.1X4Mm","40004311","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X78Mm Xl25 Recess","40004312","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X42Mm St Xl25 Recs","40004313","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2055","2055","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X48Mm St Xl25 Recs","40004314","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox Lat L 6 H","40004315","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L80Mm Dia6.5Mm Thrd","40004316","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","11107.89","11107.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L215Mm Dia5Mm Ns Can","40004317","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","11298.31","11298.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Mic Set 45Cm N","40004318","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","815.77","815.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L L250Mm Dia10Mm","40004319","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 3-5 Tib Cd","40004320","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","852.56","852.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib G-H/ Fem","40004321","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L7Cm Hd L15.9Mm","40004322","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","806.64","806.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infinity Everlast Size 2 7Mm","40004323","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4511.83","4511.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Med Ant 7H 91Mm","40004324","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1349.12","1349.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W16.5Xl37Mm Thk2Mm","40004325","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 6Mm Full For Acss","40004326","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2625","2625","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14Xh6Xl12Mm 13D","40004327","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3071.25","3071.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili L7Cm Od7Fr Cath","40004328","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","270.9","270.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L28Mm Od4Mm Poly","40004329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1931.62","1931.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L90Mm Dia3.5Mm","40004330","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","604.97","604.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia7.5Mm Post","40004331","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3008.38","3008.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 5Mm Flx Disp","40004332","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope Vid Su Bflex 5.8","40004333","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L80Mm Dia5Mm Ti","40004334","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Od5Mm Ti","40004335","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","901.08","901.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4.3Mm Lng","40004336","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","870.37","870.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4.3Mm Sht","40004337","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","870.37","870.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X26Mm Dst Tib","40004338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.55","71.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X45Mm Fens Canc","40004339","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1836.45","1836.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X50Mm Fens Canc","40004340","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1836.45","1836.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L90Mm Dia5.5Mm Ti","40004341","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","522.9","522.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cross Connector Spinal 49-59Mm","40004342","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1057.35","1057.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar L18Cm Dia23Mm Il Aaa","40004343","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16580.81","16580.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im 10X420Mm Tbl","40004344","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2494.71","2494.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bn Tbl Dstl 12H 213Mm35Mm","40004345","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2047.5","2047.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Xl25 Tib","40004346","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","411.6","411.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X36Mm Xl25 Tib","40004347","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","411.6","411.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X30Mm Xl25 Tib","40004348","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","411.6","411.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bn Fib 7H 125Mm 2.7 3.5Mm","40004349","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","908.84","908.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer 12Mm Long Flex Monobloc","40004350","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1556.1","1556.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer 10.5Mm Lng Flxbl Monblc","40004351","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1556.1","1556.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"End Cap Nl Tbl 5Mm Ext","40004352","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","447.3","447.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L345Mm Dia10Mm Tbl","40004353","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2353.5","2353.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X32Mm Canc Hex Hd","40004354","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","422.1","422.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovsclr L9.5Cm Dia20Mm","40004355","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7206.68","7206.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Linesider Ti Rod 5.5Mm 40Mm","40004356","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X40Mm Cannulat","40004357","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X50Mm Cannulat","40004358","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.4Mm Niti","40004359","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia12Mm Ns Long Cann","40004360","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1482.78","1482.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L120Mm Dia4.2Mm Xln","40004361","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","633.36","633.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Id L360Mm Dia9Mm Tib Tn","40004362","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2183.37","2183.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32Mm St Xl25 Rcs","40004363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","627.37","627.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Med Dst L 12H","40004364","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2109.26","2109.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Fem 3-5 Tib Cd H14Mm","40004365","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2172.85","2172.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Oct No1 4X22Mm","40004366","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Oct No1 4X24Mm","40004367","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Oct No2 5X28Mm","40004368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1502.55","1502.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 3.5Mm Dia Cocr 120Mm","40004369","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1454.25","1454.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Occipitocervical 4.5X32Mm","40004370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1822.28","1822.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L18Mm Od4Mm Poly","40004371","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1822.28","1822.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal Sm Lat Perla","40004372","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","878.85","878.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Crvcl 16X14Mm 6Mm","40004373","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4375.32","4375.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Crvcl 16X14Mm 7Mm","40004374","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4414.93","4414.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Crvcl 16X14Mm 8Mm","40004375","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4521.57","4521.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl W16.5Xl48Mm Thk2Mm","40004376","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1419.08","1419.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscp W16Mm Cath 7Fr L230Cm","40004377","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2945.48","2945.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Balln 4Mmx2Cm Max Forc","40004378","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","471.32","471.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasclr 0.035Inx260Cm","40004379","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","64.05","64.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge 8.5Fr L25Cm 0.038In","40004380","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","203.92","203.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 5Fr L10Cm L40Cm Dia0.018","40004381","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","364.42","364.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Reamng L950Mm Dia3Mm 3.8Mm","40004382","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","326.51","326.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L400Mm Dia3.2Mm","40004383","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","208","208","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X88Mm St Xl25 Rcss","40004384","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.14","500.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia10Mm Ds 5Deg","40004385","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2812.68","2812.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Lsr 365Um Holm Disp","40004386","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","930.47","930.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40004387","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","102.42","102.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Int 60Mm Ln Thck Tiss","40004388","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","161.88","161.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Connection M6","40004389","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","325.5","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Graft Lg 8Cc 10Ml St","40004390","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","8424.88","8424.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cmf Mini 2X3H Broad","40004391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","667.8","667.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Holmium Masterpulse 2100","40004392","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","877.8","877.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Brst Tiss 500Cc Sil","40004393","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2753.98","2753.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agiliti Fbr Su 272Um","40004394","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","751.8","751.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agiliti Fiber Ru 940Um","40004395","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","796.91","796.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X15Mm Cancellous","40004396","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","132.5","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Size E Dia54Mm 11H","40004397","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4066.79","4066.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L110Mm Dia5.5Mm Ti","40004398","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L120Mm Dia5.5Mm Ti","40004399","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L80Mm Dia8Mm Il","40004400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L90Mm Dia8Mm Il","40004401","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771.88","1771.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L24Mm Od4Mm Polya","40004402","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1160.92","1160.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L12Cm Hd Dia3Mm Dst","40004403","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","766.39","766.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasclr 0.025Inx145Cm","40004404","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","44","44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Compr Hdlss","40004405","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 340Cc Dia13.4Cm","40004406","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1125","1125","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia7Mm Cannulated","40004407","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1254","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia9Mm Cannulated","40004408","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1254","1254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L400Mm Dia3.1Mm","40004409","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","394.8","394.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L500Mm Dia3.1Mm","40004410","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","394.8","394.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix 3.1Mm Steinman","40004411","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","535.5","535.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L6In Dia2.5Mm Fen Disp","40004412","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","747.6","747.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia5Mm 3.5Mm","40004413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L100Mm Dia5Mm 3.5Mm","40004414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","913.5","913.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4Mm Disp","40004415","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","747.6","747.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L6In Dia4Mm Free Hnd","40004416","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","747.6","747.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute 18Ml Ha","40004417","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","6945.75","6945.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thermoplastic Flexible Disp","40004418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L200Mm Dia5.5Mm Ti","40004419","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L30Mm Dia4.5Mm Ti","40004420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.05","1146.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40Mm Dia4.5Mm Ti","40004421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.05","1146.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Model Bne Alliance Glen Guid R","40004422","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1795.5","1795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 7Mm Mini Shldr Cocr","40004423","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4265.63","4265.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cup Hum Dia36Mm +3Mm Polyeth","40004424","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2671.5","2671.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Cort Ti","40004425","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","206.45","206.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Canc Cann","40004426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","360.27","360.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X34Mm Canc Cann Lng","40004427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Cort Hex","40004428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.92","47.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X55Mm Cort Hex","40004429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.04","47.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X48Mm Canc Hex Hd","40004430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Canc Hex Hd","40004431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.26","364.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Canc Hex Hd","40004432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Canc Hex Hd","40004433","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8Mm Dia2Mm Ti","40004434","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","152.25","152.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia9Mm L Fem","40004435","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2788.5","2788.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L32Mm Dia4Mm Sm Dk","40004436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","655.62","655.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L34Mm Dia4Mm Sm Dk","40004437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","694.96","694.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L50Mm Dia3.5Mm D","40004438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","655.62","655.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinl 5.5X40Mm Lordotic Ti","40004439","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1811.25","1811.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire L500Mm Dia1.4Mm","40004440","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","218.16","218.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X80Mm Lord Ticp","40004441","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Rod Mis 5.5Mm 55Mm Curved","40004442","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X55Mm Cann 2Ld","40004443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mis Set Screw","40004444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 6.5X50Mm Lord Ti","40004445","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1811.25","1811.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L110Mm Dia5.5Mm","40004446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1027.33","1027.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade 14Mmx25.5Mm St","40004447","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","125.67","125.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Endoscp 5.2Fr L65Cm","40004448","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","658.29","658.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surgical 13.5Mm Lng Flx","40004449","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1556.1","1556.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Surgical 14Mm Lng Flx","40004450","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1556.1","1556.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Dstl R Fblr 4H Lok","40004451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","922.5","922.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm Comprssn","40004452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Comprssn","40004453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","644.28","644.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Comprssn","40004454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Agile Esph Dia 23Mm 120Mm","40004455","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4025.22","4025.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 8H 111Mm Ti Lcp","40004456","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","609","609","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Cort Hex","40004457","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.03","49.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Sut Multfi Scorpion","40004458","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.6Mm Drill Disp 2.6 Fibertak","40004459","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","409.5","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od47Mm Id28Mm Fem","40004460","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","949.67","949.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm Nk L+15.5Mm","40004461","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","897.75","897.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz5 L120Mm Nk L34Mm","40004462","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2590.65","2590.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Emg L12Mm Subderm 4","40004463","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X13Mm Cort T8","40004464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","112.5","112.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Guide 33Mm Hex Hd Nxgn","40004465","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","167.48","167.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L154Mm Dia34Mm Shth","40004466","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","28843.6","28843.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L55Mm Od5.4Mm Post","40004467","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","546","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Thor 32Fr L23In Blue","40004468","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","18.56","18.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 3.8Mm Flex Disp","40004469","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +4Mm Offset","40004470","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1295.06","1295.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Sz C Dia28Mm 10Deg","40004471","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1258.4","1258.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Od48Mm Id28Mm Fem Hd Mdm X3","40004472","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1280.4","1280.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acet Sz E Id42Mm Hip X3","40004473","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2075.35","2075.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Artfcl W13Xh5Xl15Mm Cerv","40004474","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7087.5","7087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Cerv Ti Lord 3.5Mmx60","40004475","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","555.57","555.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Canc Hex Drv","40004476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X40Mm Polyax","40004477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1323.69","1323.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X20Mm Post Pedcl","40004478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1370.02","1370.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X50Mm Cort Ft St","40004479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","75.68","75.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L31Mm 4H Bilat Ss","40004480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","428.4","428.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L12Mm Dia4Mm Ant","40004481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480","480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14Mm Dia4.5Mm","40004482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480","480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L20Mm","40004483","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","214","214","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40004484","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1221","1221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L145Mm Dia3.2Mm Qc N","40004485","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","175.11","175.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L465Mm Dia12Mm Cann","40004486","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","752.71","752.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L80Mm Dia7Mm Thread","40004487","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1723.05","1723.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X50Mm Post Pedcl","40004488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1771","1771","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X55Mm Post Pedcl","40004489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1725","1725","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X40Mm Post Pedcl","40004490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.5","1828.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X50Mm Post Pedcl","40004491","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1725","1725","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X55Mm Post Pedcl","40004492","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1725","1725","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X200Mm Strght Ti","40004493","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","590","590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire L500Mm Dia1.4Mm","40004494","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","216","216","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X45Mm Post Pedcl","40004495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1766.4","1766.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X75Mm Lordotic","40004496","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","590","590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Compressn","40004497","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","604.16","604.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm Compressn","40004498","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","590","590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X50Mm St Xl25","40004499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","597.5","597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Femoral 6-9Tib Gh","40004500","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1952.25","1952.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphinctom 44Cann 30Mmx260Cm","40004501","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","836.28","836.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Dil 9Fr L6.1In Mech Rot","40004502","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","2542.5","2542.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm Nk L+3.5Mm","40004503","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","822","822","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L30Mm Std Lev2","40004504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1500","1500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Tib Cd Fem 3-9 H13Mm","40004505","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Sur Compl 6.5 7Mm Screw","40004506","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","803.29","803.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L405Mm Dia10Mm Tib St","40004507","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2479.59","2479.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 7 L130Mm Nk L30Mm","40004508","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3145.78","3145.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Od28Mm -2.5Mm Offset","40004509","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1710.45","1710.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Fem 6-9Tib Gh H11Mm","40004510","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Hum Dia40Mm Std Thck +6Mm","40004511","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2489.29","2489.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia6.5Mm Hex","40004512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","158.24","158.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X64Mm St Xl25","40004513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.14","500.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Crvcl 16X14Mm","40004514","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4512.95","4512.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Vbr H13-17.5Mm","40004515","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","14435.89","14435.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Vbr Dia13Mm 5Deg Angulat","40004516","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3278.8","3278.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Spinl Dia13Mm 10Deg Ver","40004517","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3183.3","3183.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinl W16.5Xl22Mm Thk2Mm","40004518","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1185","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrpc Spnl H16-21.5Mm Dia13Mm","40004519","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","14435.89","14435.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L58Mm Std Bilat Ant","40004520","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1959.2","1959.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X40Mm Multiaxial","40004521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L40Mm Dia4.5Mm","40004522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L500Mm Dia5.5Mm Ti","40004523","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1316.7","1316.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spinal Span L30-34Mm","40004524","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2344.94","2344.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X62Mm Xl25 Recess","40004525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X64Mm Xl25 Recess","40004526","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.77","534.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ball Spike Lng L400Mm Dia6.5Mm","40004527","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","738.11","738.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spike Surg L300Mm Strght Ball","40004528","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","707.15","707.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X52Mm Compr Hdlss","40004529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X52Mm Compr Hdlss","40004530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L228Mm Dia1.4Mm","40004531","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","122.79","122.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem L135Mm Dia14Mm Hip","40004532","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5374.93","5374.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L138Cm Blln L6Mm","40004533","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","130.19","130.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Knot Push Sut Cut Slt Cann","40004534","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","306.6","306.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Barigel Procedure Packs","40004535","CDM","270","RC","C1889","HCPCS","","","facility","both","","","","9117.75","9117.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cartridge Novostitch + 2-0 Sut","40004536","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Ank Cort","40004537","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","92.05","92.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Set Spine Perla Strl","40004538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305.73","305.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidepin Endoscp L13.5Mm","40004539","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","257.4","257.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 8 H R Dst Fib Ss","40004540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1256.1","1256.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt L4.5Cm Dia20Mm","40004541","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6683.62","6683.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal L14Mm Od4Mm Polyax","40004542","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L80Mm Dia3.5Mm","40004543","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","616.6","616.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L16Mm Od4Mm Polya","40004544","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1864.62","1864.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Bone Graft 7Mm","40004545","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1098.1","1098.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interfrence L20Mm Od2Mm","40004546","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409.58","409.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X40Mm Cann Sht Thrd","40004547","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X48Mm Cann Sht Thrd","40004548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia8.5Mm R Hum","40004549","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2140.51","2140.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prox 1H 69Mm Ss Lcp 3.5Mm Scrw","40004550","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1283.5","1283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Reten Qc Sur Drvr 12Mm Hex","40004551","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","924.92","924.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Reten Sht Qc Sur Drvr 12Mm","40004552","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","878.56","878.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 6X3 H Std 22X54Mm Ti","40004553","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1290.56","1290.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Nephstmy L15Cm Blln D10Mm","40004554","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","635.38","635.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone Gent Hi Visc Sys","40004555","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.43","1012.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Artfcl H6Mm 13X17Mm Ti","40004556","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7498.44","7498.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L61/31Mm Dia1Mm","40004557","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L70/39Mm Dia1.1Mm","40004558","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L88/57Mm Dia1.5Mm","40004559","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L83/57Mm Dia1.5Mm","40004560","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L60/29Mm Dia1.3Mm","40004561","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L55Mm D1.3Mm J Latch","40004562","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L62/31Mm Dia1.5Mm","40004563","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L57/31Mm Dia1.5Mm","40004564","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","195.1","195.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.5Mm Cann","40004565","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia12Mm 10Mm Extn","40004566","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","282.13","282.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L150Mm Dia1.4Mm","40004567","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","256.95","256.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L150Mm Dia1.1Mm","40004568","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","215.67","215.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Feml 10-12 Tib Gh","40004569","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1704.96","1704.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L71/41Mm Dia2Mm","40004570","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Asep Dbl Strnd","40004571","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2751","2751","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Implant Incl 4.75Mm","40004572","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1264","1264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrv Bg 140Ml","40004573","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","909.18","909.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L66/41Mm Dia2Mm","40004574","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.06","184.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt L4.5Cm Dia23Mm","40004575","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6683.62","6683.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Blk 8X14X11Mm","40004576","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1726.15","1726.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Ped L11Cm Dia4Mm","40004577","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","335.24","335.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Iu 6.7Mmx6Cm Wht Sil Sft","40004578","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","412.86","412.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L80Cm Dia8Mm Ptfe","40004579","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","3679.79","3679.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L50Cm Dia8Mm Rng","40004580","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","3643.82","3643.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L80Cm Dia6Mm Ptfe","40004581","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","3666.69","3666.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L50Cm Dia6Mm Ptfe","40004582","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2877.18","2877.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Cv 40Cm 6Mm Std Wl Strch","40004583","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","796.32","796.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L10Cm Id6Mm Std","40004584","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","350.7","350.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc 8Mm Dia 40Cm Len","40004585","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","796.32","796.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L10Cm Id8Mm Strtch","40004586","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","350.7","350.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc Fus Bioline 8 Mmx40","40004587","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2014.5","2014.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Bio Tiss W1Xl6Cm","40004588","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","471.72","471.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tool Reduc L78Mm Dia2.4Mm Slf","40004589","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1782.24","1782.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L15Mm Dia3.5Mm An","40004590","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1004.88","1004.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L6Mm Dia5.5Mm Ti","40004591","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","199.5","199.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia9Mm R Fem","40004592","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2937.22","2937.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Thk1Mm 4 H L Subcon","40004593","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1141.68","1141.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia7Mm R Hum","40004594","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2140.51","2140.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Hndpc Camera Hd Cbl Disp","40004595","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1103.69","1103.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uretr 8Fr L24Cm Firm Tri","40004596","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","422.1","422.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Cerv 16X14Mm 10Mm","40004597","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Ti Cerv 16X12Mm 6Mm","40004598","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4353.29","4353.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L72Mm Std Lev 4 Ant","40004599","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1785","1785","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L14Mm Std Lev 1 Ant","40004600","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1669.5","1669.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrd Spc 1-6-2Mm 8Fr L115Cm","40004601","CDM","278","RC","C1732","HCPCS","","","facility","both","","","","4735.65","4735.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Us 10Fr L90Cm Yel","40004602","CDM","278","RC","C1759","HCPCS","","","facility","both","","","","3703.37","3703.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Map D Blu Crv 7Fr L115Cm","40004603","CDM","270","RC","C1732","HCPCS","","","facility","both","","","","2643.58","2643.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X45Mm Post","40004604","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1783.77","1783.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Del Invictus Fen","40004605","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1311.75","1311.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosser Iq Us Cto Device","40004606","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2875.45","2875.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recon Supp Cath Str Tapr 110Cm","40004607","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1069.66","1069.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40004608","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1286.12","1286.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.55Mm Cmf Ft Slf","40004609","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.3","237.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interfer L23Mm Dia5Mm","40004610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1049.12","1049.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Instr Ant Cruce Lig Disp","40004611","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1374.6","1374.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Gh Fem 10-12","40004612","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Cortical","40004613","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.93","174.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm Cortical","40004614","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.43","185.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm Cortical","40004615","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.43","185.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone L20Mm Dia2Mm Smooth","40004616","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.93","174.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fix L22Mm Dia2Mm Smth","40004617","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.93","174.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fix L24Mm Dia2Mm Smth","40004618","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.93","174.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia2.5Mm Peg","40004619","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","174.93","174.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rt 8H Ext H-Plt Ss","40004620","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","940.15","940.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prox L 8H L Bend","40004621","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2691.51","2691.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 H St 3.5Mm Lok","40004622","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","989.04","989.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L200Mm Dia2.8Mm Qc 3","40004623","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","384.53","384.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti Rod Mis 5.5Mm 40Mm Cruved","40004624","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X35Mm Post","40004625","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1824.9","1824.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X18Mm Va St Ti","40004626","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","267.75","267.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X30Mm Post","40004627","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L80Mm Std Lev 4 Ant","40004628","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1343","1343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interfer L20Mm Dia7Mm Ti","40004629","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","356.16","356.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox L 8 H St L","40004630","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2765.05","2765.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.4X10Mm T8 Stardrv","40004631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","249.85","249.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X50Mm Cort Hex","40004632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.06","78.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 8Fr L25Cm Hemstat","40004633","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","38.71","38.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prox R 4 H St Sm","40004634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2288.12","2288.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L30Mm Dia2Mm","40004635","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","638.6","638.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X7Mm Cort T8","40004636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","145.94","145.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3 H St Spr Ss Lp","40004637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","563.18","563.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl R 14 H St Crv","40004638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3007.94","3007.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Impl Std Biocomposite","40004639","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2409.34","2409.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L12Cm Aort","40004640","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","14527.9","14527.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L14Cm Dst D12Mm","40004641","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6785.8","6785.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L12Cm Dst D12Mm","40004642","CDM","272","RC","C1874","HCPCS","","","facility","both","","","","6785.8","6785.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Lap Seal Shft L37Cm Dia5Mm","40004643","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1027","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral 160Mm Sz 8 Std","40004644","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3049.03","3049.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinl W16.5Xl28Mm Thk2Mm","40004645","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1185","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Ef Fem 10-11","40004646","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Cath L4Ft 26 To 20 Pin","40004647","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","963.9","963.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applicator Endoscp L34Cm W/ Ss","40004648","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","164.79","164.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ulna X-Artc Prox L 6","40004649","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1890.38","1890.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ortho L10In Dia2.4Mm","40004650","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","312.9","312.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plug Tunn 7-12Mm Bone Cann","40004651","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","97.31","97.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Guide Dia1.2Mm L9Mm","40004652","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","105.2","105.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H27Mm Dia50Mm Shldr","40004653","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2376.32","2376.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wallflex Duod Sft Uc 27/22Mm","40004654","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3317.38","3317.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L65Cm Gwire","40004655","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.2X150Mm Lng Smth Tip","40004656","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.2","118.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L10Cm Dia12Mm Nit","40004657","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16250.55","16250.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt L12Cm D26X14.5","40004658","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","20251.34","20251.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L12Cm Dst Dia23Mm","40004659","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7192.95","7192.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X22Mm Compr Hdlss","40004660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Sur Dia2.3Mm Ss Thrd","40004661","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","113.62","113.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L55Mm Dia5.5Mm Long","40004662","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","695.31","695.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L70Mm Dia5.5Mm Long","40004663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","695.31","695.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L70Mm Dia7Mm Short","40004664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","842.31","842.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Evar Int Il L7Cm","40004665","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4535.22","4535.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X24Mm Compr Hdlss","40004666","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1027","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X35Mm Post Pedcl","40004667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1666.32","1666.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X24Mm Compr Hdlss","40004668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X58Mm Xl25 Recess","40004669","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Compr Hdlss","40004670","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ultrasound 10Fr L90Cm","40004671","CDM","278","RC","C1759","HCPCS","","","facility","both","","","","3843.54","3843.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L12Cm Dst D12Mm","40004672","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6785.8","6785.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg L100Mm Dia10.5Mm","40004673","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1280.49","1280.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4X4 H T Plt 56Mm R","40004674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","582.83","582.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem L75Mm Dia14Mm","40004675","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2788","2788","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 3-5 Tib Ef","40004676","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tib Size Ef Thk10Mm L","40004677","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1904.85","1904.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vascular Fusion Bioline","40004678","CDM","278","RC","L8670","HCPCS","","","facility","both","","","","2531.25","2531.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinl W16.5Xl12Mm Thk2Mm","40004680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1208.7","1208.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L12Mm Od2.5Mm Ant Cerv","40004681","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","333.9","333.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Calcan L Lg St 70Mm","40004682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1869.52","1869.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X72Mm Xl25 Recess","40004683","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X74Mm Xl25 Recess","40004684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Compress","40004685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Calcan L Lg St 70Mm","40004686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1970.05","1970.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 2X3 H 32Mm Ss Mod","40004687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.42","1022.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Dbl Ld Fibertak Dx","40004688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","879.27","879.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinl Fav Ang Fen Si Cor","40004689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3108.47","3108.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Surg L18In Nit Blunt","40004690","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","200.55","200.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Lord Exp 12 X 10 X 25Mm 20","40004691","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fix L24Mm Dia2Mm Dst","40004692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.22","185.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia3.5Mm Cort","40004693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","185.22","185.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl 2X6 H St 44Mm","40004694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.43","1022.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaft Scrwdrvr T6 Stardrv Self","40004695","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","806.86","806.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wand Ablat Shaft Dia3.75Mm Tip","40004696","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X50Mm Canc Hex","40004697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.42","365.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Hex Drive","40004698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.29","343.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X34Mm Hex Drive","40004699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.29","343.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L170Mm Dia4.5Mm 1.7Mm","40004700","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","641.7","641.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Ortho Dia10Mm For 4.5Mm","40004701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","60.41","60.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Finger Jt 00 L25.4Mm","40004702","CDM","278","RC","L8630","HCPCS","","","facility","both","","","","2950.12","2950.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Tib Ef Fem 6-9 H18Mm","40004703","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia12Mm Short Cann","40004704","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1201.18","1201.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia10Mm Tib","40004705","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2522.25","2522.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne 5X74Mm St Xl25 Recess","40004706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 7 H T Shp For Sm Bne","40004707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1632.46","1632.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16Mm Dia2.4Mm Cort","40004708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1018.71","1018.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24Mm Dia2.4Mm","40004709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1018.71","1018.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70Mm St Xl25","40004710","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","627.37","627.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia2.4Mm Ti","40004711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1067.5","1067.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L3Mm Dia1.8Mm Lt","40004712","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","783.97","783.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X64Mm St Xl25","40004713","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","591.86","591.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L4Mm Dia1.8Mm Lt","40004714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","783.97","783.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60Mm St Xl25","40004715","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","591.86","591.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Oct 4X100Mm Post","40004716","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Med Lat No1 3.5X16Mm","40004717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blln Kyphoplasty 1St Frac","40004718","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","5408.6","5408.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosthesis Penile 18Cm 1 Pmp 2","40004719","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","15455.12","15455.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosthesis Penile Resvr 100Ml","40004720","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","3622.15","3622.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infl Restr Ams 700 Acc","40004721","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","1515.69","1515.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.7 Va Lok Calcnl Plating Sys","40004722","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","749.7","749.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotid L30Mm D10Mm","40004723","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3643.11","3643.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Periph L15Cm Dia4Mm","40004724","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1658.05","1658.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Periph L20Cm Dia6Mm","40004725","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Periph L60Cm Dia32Mm","40004726","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1564.2","1564.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Periph L60Cm Dia28Mm","40004727","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1564.2","1564.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb  Periph L60Cm Dia24Mm","40004728","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1564.2","1564.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Periph L1Cm Dia2Mm 3D","40004729","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1248.2","1248.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L28Mm Dia4Mm No1","40004730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Seal 5Ml Spine Dura","40004731","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","1084.51","1084.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Dst Tib","40004732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","72.98","72.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X26Mm Va Ank Ft","40004733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.43","235.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X85Mm Pelv Cort","40004734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","63.9","63.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X90Mm Pelv Cort","40004735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","65.76","65.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95 Mm Od3.5 Mm Pel","40004736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","62.04","62.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L88Mm 12 H Ss Lok","40004737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","799.32","799.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn R 3X5 H T Plt 10X67Mm","40004738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","637.35","637.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X42Mm Cort Ft","40004739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","79.61","79.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od56Mm Id28Mm Fem","40004740","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","881.01","881.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Cv Cath 6Fr L20Cm Bas Poly","40004741","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","146.28","146.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Hexalobe","40004742","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","273","273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinl Fav Ang Fen Si Cor","40004743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3017.93","3017.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia8.5Mm","40004744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1327.9","1327.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L55Mm Dia8.5Mm","40004745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1327.9","1327.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L55Mm Dia7.5Mm","40004746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1350.02","1350.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinl L500Mm Dia5.5Mm Post","40004747","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","212.58","212.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Core Fen Poly Screw 6.5Mmx40Mm","40004748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3017.93","3017.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Int 45X3.5Mm Reld","40004749","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","220.94","220.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X40Mm","40004750","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2776.85","2776.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia6.5Mm","40004751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2776.85","2776.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spinl Dia5.5/6Mm Cdh","40004752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","422.94","422.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L80Mm Dia5.5Mm Perc","40004753","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1514.13","1514.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Surg 24In Blunt Thrd","40004754","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","147.97","147.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Lap L20Cm Shft Dia10Mm","40004755","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","769.22","769.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pack Arthscp Acl Pcl Drl Tip","40004756","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","692.16","692.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Int W11Xl20Mm Lig Lp","40004757","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L4In Dia0.062In","40004758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","124.05","124.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L12Cm Dst D12Mm","40004759","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7192.95","7192.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 16Fr L33Cm","40004760","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","831.59","831.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 10-12 Tib Gh","40004761","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055.58","2055.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X5Mm Cort Ft Slf","40004762","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","150.58","150.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili 7Fr L5Cm Plas Dbl","40004763","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","149.91","149.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili L80Mm Dia10Mm Cath","40004764","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3209.5","3209.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili 10Fr L5Cm Plas Dbl","40004765","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","147.28","147.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.85X8Mm Mand Slf","40004766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.8","877.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 8.5Fr L63Cm 45Deg","40004767","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","451.5","451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc L175Cm D0.025In","40004768","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","493.5","493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 7-12 Tib Gh","40004769","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"6.5X45Mm Polyax Fen Cann Xtab","40004770","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2385.8","2385.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spinal Perla Tl","40004771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","432.39","432.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X45Mm Post","40004772","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","884.8","884.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Z Rod Spnl L300Mm Dia5.5Mm Yel","40004773","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L60Mm Dia8Mm Cath","40004774","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3537","3537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L49Mm D36X36Mm Cath","40004775","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5879.28","5879.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc Prss L185Cm","40004776","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","1192.9","1192.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 0.032Inx180Cm","40004777","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","63.59","63.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 10X85Mm Ti","40004778","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4585","4585","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Ves L37Cm Nonstick Nano","40004779","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","940.29","940.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Knee Size Ef L+0Mm R Tib Artc","40004780","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","437.3","437.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 5Cc Putty Dmb","40004781","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1156.88","1156.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 10Cc Putty Dmb","40004782","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1901.57","1901.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm Sz 6 Std Offset","40004783","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3049.03","3049.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Uplr Dia46Mm Mod Cathcart","40004784","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1057.35","1057.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L36Mm D4Mm Ss Cann","40004785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 Std R Knee","40004786","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3332.64","3332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X14Mm Post Pedcl","40004787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1082.3","1082.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14.5Xh7Xl11.5Mm","40004788","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3668","3668","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinl L15Mm Thk1.9Mm Ant","40004789","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2776.85","2776.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal 6X18X16 Titan Ti","40004790","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5109","5109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fixation Temporary","40004791","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","306.1","306.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X38Mm Cort","40004792","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Hexalobe","40004793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal W16.5Xl51Mm","40004794","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1343","1343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib C-D Fem 3-5","40004795","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X45Mm Cort","40004796","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X22Mm Post Pedcl","40004797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1373.02","1373.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X24Mm Post Pedcl","40004798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1455.4","1455.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.5X30Mm Post Pedcl","40004799","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1373.02","1373.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Void Putty 5Cc Dbm","40004800","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1699.92","1699.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X24Mm Ank Cort Ft","40004801","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.35","118.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L36Mm Dia4Mm Cort Ss","40004802","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","69.3","69.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cover Bur H Dia12Mm Thk0.3Mm","40004803","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","644.25","644.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cover Bur H Dia15Mm Thk0.3Mm","40004804","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","643.31","643.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X48Mm Stardrv","40004805","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","267.12","267.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod External Fixation Carbon F","40004806","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.26","48.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Compr Hdlss","40004807","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W9Xl117Mm Thk1Mm","40004808","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X24Mm Canc Hex Drv","40004809","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","45.97","45.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Hexalobe","40004810","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Hexalobe","40004811","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","212.1","212.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ti L20Mm Od3.5Mm","40004812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L11.5Cm Dia20Mm","40004813","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5934.3","5934.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L12Cm Dst","40004814","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6112.33","6112.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6H R Scapular Acrmn","40004815","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2884.62","2884.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applier Clp 12Fr L86Cm","40004816","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","6222.5","6222.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Guide 16Fr L62Cm","40004817","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","2782.38","2782.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X54Mm Canc Hex Drv","40004818","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Canc Hex Drv","40004819","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","380.65","380.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rad Dst Dors 2X5 H","40004820","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1047.69","1047.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rad Clmn Dst Dors 6","40004821","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1029.78","1029.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm Sz 6 Std Offset","40004822","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3049.03","3049.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Post Pedcl Thorlum","40004823","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2370","2370","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz D Dia48Mm 3 Clus","40004824","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","638.51","638.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.85X6Mm Mand Slf","40004825","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","184.76","184.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X38Mm Va T25 Strdrv","40004826","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.14","396.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sm L28Mm Dia2.5Mm","40004827","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","689.43","689.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia2.7Mm Cort","40004828","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","408.24","408.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 1St Mt L Sm 42Mm","40004829","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3395.52","3395.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut L19.1Mm Dia5.5Mm","40004830","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Tunn Tool L50Cm","40004831","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L18Mm Dia4.5Mm","40004832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504","504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 225Cc Dia10.9Cm","40004833","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","546","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Sz G Dia36Mm 10Deg","40004834","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1286.91","1286.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Crush Canc 30Cc 1-8","40004835","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","600.98","600.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Chip Fd Demin Canc","40004836","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1014.81","1014.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 1Cc Dbm Gel Fd","40004837","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","385.14","385.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 10Cc Dbm Gel Fd","40004838","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1795.04","1795.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Cmplt Opn Rmr Asmb","40004839","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1998.7","1998.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Nerve Stim Anchor Spare","40004840","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurostim Ld L90Cm 5Mm Spc Kit","40004841","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng30030Ux Onyx","40004842","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng45015Ux Onyx","40004843","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead L70Cm Surpass Kit","40004844","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X64Mm Cort Hex","40004845","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","56.25","56.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X32Mm Cort Hex","40004846","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 2.5X270Mm Lng Smth Tip","40004847","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","111.51","111.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tibiotalar Lat Sm","40004848","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3930.79","3930.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L45Mm Dia4.5Mm Cort","40004849","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","816.48","816.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40Mm Dia4.5Mm Cort","40004850","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","345.87","345.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L45Mm Dia4.5Mm Cort","40004851","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","345.87","345.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X50Mm Ank Cort","40004852","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","345.87","345.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3Mm For Ank Fus","40004853","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","567.84","567.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X45Mm","40004854","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X30Mm","40004855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X70Mm Post","40004856","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X80Mm Post","40004857","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X50Mm Post","40004858","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnal L20Mm Post Lat","40004859","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1172.36","1172.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blunt Blade 23X70Mm Lght Green","40004860","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blunt Blade 23 X 75Mm Orange","40004861","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Micro-Blunt Blade 14X70Mm Lght","40004862","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Micro Blunt Blade 14X75Mm Orng","40004863","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Nim Emg Et Sz 6","40004864","CDM","272","RC","","","","","facility","both","","","","968.1","968.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Micro-Teeth Blade 14X70Mm Lght","40004865","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tfna Screw 70Mm","40004866","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1691.81","1691.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"04.038.310 Synthes Tfna Helica","40004867","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1782.38","1782.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.118.013 Synthes 2.7/3.5 Va","40004868","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3997.88","3997.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.118.412 Synthes 2.7 Va Lcp","40004869","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2432.5","2432.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Short 13Cm","40004870","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1405.1","1405.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fogarty Insert Soft 33Mm","40004871","CDM","271","RC","","","","","facility","both","","","","50.23","50.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applicator, Endoscopic","40004872","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","196.44","196.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sclerosol Intrapleural Aerosol","40004873","CDM","271","RC","","","","","facility","both","","","","352.27","352.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 194Mm Ss 3.5Mm Scr 8 Hl","40004874","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1948.8","1948.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L116Mm 4 H St L","40004875","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.2","1516.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 116Mm Ss 2.7/3.5Mm Scr 4","40004876","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1672.65","1672.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 124Mm Ss 2.7/3.5Mm Scr","40004877","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1248","1248","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lng 127Mm 2.7/3.5Mm Scr","40004878","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.1","1598.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Xlng 153Mm Ss 2.7/3.5Mm","40004879","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.1","1598.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Shrt 75Mm Ss 2.7/3.5Mm","40004880","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1598.1","1598.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L195Mm 8 H St L","40004881","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2185","2185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia14Mm Cann Flx For S","40004882","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1221","1221","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arm Aiming R For 4.5Mm Va Crv","40004883","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","4499.25","4499.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Intraocular +24.5 Diopter","40004884","CDM","276","RC","V2788","HCPCS","","","facility","both","","","","1567.65","1567.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W25.5Xl110Mm Xln","40004885","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2111","2111","","","","","","","","","","","","","Gross Charge Type: Standard"
"Micro-Teeth Blade 14X75Mm Orng","40004886","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Short Teeth Blade 23X70Mm","40004887","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Short Teeth Blade 23X75Mm","40004888","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Long Teeth Blade 23X70Mm","40004889","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Long Teeth Blade 23X75Mm","40004890","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X16Mm Compr Hdlss","40004891","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Suture 3X12.2Mm Peek","40004892","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","535.5","535.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Surg Instr 3.5Mm Drlbt","40004893","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1112.07","1112.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Es L2300Mm Loop Dia20Mm","40004894","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","76.38","76.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Proc 16Fr Lawrence Suprpub","40004895","CDM","278","RC","C2627","HCPCS","","","facility","both","","","","120.35","120.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Sz 2 Dia3.5Mm Bone","40004896","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1438","1438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flarehawk Shim Lordotic 10 Mm","40004897","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4126.5","4126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Sht 25Mm Fh9 Ti","40004898","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4126.5","4126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Od36Mm +7.5Mm Offset","40004899","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1286.12","1286.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Dia6.5Mm","40004900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","139.39","139.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L35Mm Dia6.5Mm","40004901","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","142.18","142.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 9.6X120Mm Sz 6 Nk","40004902","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2573.82","2573.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X56Mm Xl25 Recess","40004903","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","437.55","437.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"L20Mm Ibt 1St Frac Osteo Intro","40004904","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","4503.23","4503.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X36Mm Compr Hdlss","40004905","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-9 Tib","40004906","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia10Mm Dst","40004907","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2890.45","2890.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm St Xl25 Rcss","40004908","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X82Mm St Xl25 Rcss","40004909","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.14","500.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X36Mm St Xl25 Rcss","40004910","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L270Mm Dia8.5Mm L Tan","40004911","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2268.94","2268.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mix Bone Cement Full Dose Pmma","40004912","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","138.86","138.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 0.018Inx80Cm","40004913","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","153.42","153.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8Mm Dia2Mm Ss St","40004914","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","298.61","298.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endoprs L12Cm Aort D26Mm","40004915","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","17045.72","17045.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X50Mm","40004916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1768.5","1768.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X90Mm Post","40004917","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X120Mm Pst","40004918","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","333.9","333.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shim Spinal 8/11X25Mm 0Deg","40004919","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4374.09","4374.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 10-12X23Mm 6Deg Shim","40004920","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4126.5","4126.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast 225Cc","40004921","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"3D Por Ti Cerv Intbdy 16X12Mm","40004922","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kwire Fix L150Mm Dia1Mm Ss","40004923","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","166.22","166.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X34Mm Xl25 Recess","40004924","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 1 Lev 18Mm","40004925","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1690.05","1690.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Tem Fix Spinal Hexalobe","40004926","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","194.67","194.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X30Mm Post Pedcl","40004927","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cross Conn Rod To Rod L50Mm","40004928","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1070.36","1070.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X16Mm","40004929","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X14Mm","40004930","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L40Mm Ant Cerv 2","40004931","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"7.5X45Mm Polyax Fen Cann Xtab","40004932","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2486.68","2486.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"7.5X40Mm Polyax Fen Cann Xtab","40004933","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2476.65","2476.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X35Mm Post","40004934","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","851.2","851.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum L122Mm Dia10Mm Std","40004935","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4512.95","4512.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"L150Cm Od2.3-3Fr Snr Cath 1","40004936","CDM","270","RC","C1773","HCPCS","","","facility","both","","","","908.5","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Vascr 20Fr L20Cm","40004937","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","56.36","56.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Cndylr R 16 H St Crv","40004938","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3065.72","3065.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Sur L750Mm Dia1Mm Ss","40004939","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","948.21","948.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.5X16Mm","40004940","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L53Mm Ant Cerv 3","40004941","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Generator Vns Therpy Lead Conn","40004942","CDM","278","RC","C1767","HCPCS","","","facility","both","","","","53030.63","53030.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Neurostim L43Cm Dia2Mm","40004943","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","12243.29","12243.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm Sz 6 Std Offset","40004944","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3049.03","3049.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X34Mm Cort Hex","40004945","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","87.81","87.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3.2Mm Scaled Add","40004946","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","502.74","502.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dia.22X60Mm Beveled","40004947","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2743.77","2743.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Surg Dia12Mm Ti Sgl End","40004948","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","604.8","604.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Centering 12/3.2Mm","40004949","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","604.8","604.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Cath Od14Fr Green Sup-F","40004950","CDM","278","RC","C2627","HCPCS","","","facility","both","","","","124","124","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lig Md Lg Polymr Weck","40004951","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","112.72","112.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dissector Lap Seal Div L10Cm","40004952","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1088.62","1088.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Ft Cort Ft","40004953","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia3.5Mm Cort","40004954","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut W/Orthocord Sz 3-0","40004955","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","987.5","987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X70Mm Cort Hex","40004956","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.01","71.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Cort Hex","40004957","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.01","71.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm Cort Hex","40004958","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.01","71.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X45Mm Cort Hex","40004959","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.01","71.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 8.5Fr L63Cm Dil","40004960","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","345.03","345.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +12Mm Offset","40004961","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","954.64","954.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X40Mm Post","40004962","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","872.87","872.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndylr R 16H St Crv","40004963","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2900.96","2900.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X18Mm St Va","40004964","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","665.35","665.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L30Mm","40004965","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315.46","315.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L10Mm Dia5.5Mm","40004966","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","598.5","598.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L50Mm Dia3.5Mm","40004967","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","616.6","616.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 2X7 H T Plt 53Mm Ss","40004968","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","865.29","865.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia2.7Mm Cort","40004969","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","497.7","497.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L4In Dia0.045In","40004970","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","19.88","19.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Dia4Mm Slf Drl","40004971","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","582.77","582.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm D5.5Mm Slf Drl","40004972","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","695.31","695.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L320Mm Dia9Mm Nk","40004973","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2748.74","2748.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fix L25Mm Dia1.2Mm","40004974","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","136.94","136.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Infrapectineal L Sm","40004975","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2083.86","2083.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 580Cc 13.8Cm","40004976","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 545Cc Dia14Cm","40004977","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Bronchscp 21Ga L2Cm Wrk","40004978","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","596.75","596.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Cndylr R 12 H St Crv","40004979","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2823.77","2823.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L4.3Mm","40004980","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","196.4","196.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 Std L Knee","40004981","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3332.64","3332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Intro Cath 5Fr L15Cm Gwire","40004982","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","113.22","113.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applier Clp Shft L9 3/8In Mult","40004983","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","406.99","406.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"9Mm Short Ti Catalyft Pl40 Exp","40004984","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10831.08","10831.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"11Mm Shrt Ti Catalyft Pl40 Exp","40004985","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","10831.08","10831.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L100Mm Dia3.5Mm Cervc","40004986","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","616.6","616.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal L32Mm Od4Mm Polyax","40004987","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 11.5X70Mm","40004988","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4585","4585","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L Dst Fib 4 H Lok Ss","40004989","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1030","1030","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump Infus Thk19.5Mm 40Ml","40004990","CDM","278","RC","C1772","HCPCS","","","facility","both","","","","19015.49","19015.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quanta Of 272Um Su Fbr","40004991","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1055.12","1055.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal L90Mm D3.5Mm Cerv Ti","40004992","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X12Mm Va","40004993","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","533.92","533.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iron Bend L150Mm For 2.7/3.5Mm","40004994","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","397.57","397.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Occipital 3.5X120Mm","40004995","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","175.56","175.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Internal L235Cm Opn 17Mm","40004996","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","531.4","531.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphere Glen Dia36Mm +3Mm","40004997","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1817","1817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adapter Hum Hd Dia25Mm Std Ti","40004998","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","567","567","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X70Mm Compr Thrd","40004999","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1813.84","1813.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 06.5Mm X 40Mm","40005000","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 06.5Mm X 45Mm","40005001","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L15Mm Post Ti","40005002","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1013.02","1013.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Delivery Cannula Alphatec","40005003","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1303.5","1303.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hook Spinal H6.5Mm Post Ti","40005004","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","955.68","955.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hook Spinal H6.5Mm Post Ti","40005005","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","955.68","955.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 05.5Mm X 45Mm","40005006","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1779.71","1779.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia4Mm Sm Dk","40005007","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","694.96","694.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28Mm Dia4Mm Sm Dk","40005008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","694.96","694.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 05.5Mm X 40Mm","40005009","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1758.86","1758.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X44Mm Cort T8","40005010","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","221.59","221.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia1.3Mm Hand","40005011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.59","259.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Humeral L122Mm Dia6Mm Pps","40005012","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4755.96","4755.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L5Mm Dia2Mm Cort Ti","40005013","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","163.59","163.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X48Mm Sterile","40005014","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.03","403.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5.5Mm Sz3 Permacord","40005015","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","878.48","878.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Human Tiss Patellar Tndn","40005016","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3340.5","3340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fix L12Mm Dia2Mm Dst","40005017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.33","196.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Persona Tasp Shim 10Mm Gh","40005018","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","561.13","561.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bone Fix L24Mm Dia2.5Mm Ft","40005019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","196.33","196.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L59Mm Thk1.9Mm Ant","40005020","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3281.57","3281.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Dia35Mm Std","40005021","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1286.12","1286.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Dia38Mm Std","40005022","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1363.29","1363.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinl L39Mm Thk1.9Mm Ant","40005023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2814.38","2814.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ballon Kyphoplasty 1St Frac","40005024","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3957.51","3957.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cartridge Kyphoplasty C8Cc","40005025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","183.99","183.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Small Prep W/Mallet Medtronic","40005026","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinl M W14Xh7Xl16Mm 6Deg","40005027","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Acif Md 8Mm 6Deg","40005028","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mm Dia19Mm","40005029","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","528.68","528.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Dia38Mm Thk9.5Mm","40005030","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","914.89","914.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X26Mm Xl25 Recess","40005031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","524.16","524.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Cd Fem 3-9","40005032","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2178.91","2178.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Absrb W/ Sz 2 36In","40005033","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1110.39","1110.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X6Mm Crss Cort","40005034","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","158.9","158.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X12Mm Mand Cort","40005035","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","125.45","125.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Graft M Rhbmp-2 4.2Mg 5Ml","40005036","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","7894.62","7894.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W14Xl34Mm 2X4 H Cmf","40005037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1070.2","1070.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W14Xl24Mm 2X3 H Cmf","40005038","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","999.47","999.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L5.5In Dia0.028In","40005039","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","21.77","21.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X42Mm Va Ft Lok","40005040","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1020.12","1020.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L17Mm Dia3.5Mm Ant","40005041","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","527.56","527.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X16Mm","40005042","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L62Mm Ant Cerv 3","40005043","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal H23-31Mm Dia20Mm","40005044","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","13191.7","13191.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal H27-38Mm Dia20Mm","40005045","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","13191.7","13191.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Spinal 29Mm Ang 10Deg","40005046","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","4165.8","4165.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Spinal 32X26Mm 20Deg","40005047","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4165.8","4165.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Lng Lok For Vert","40005048","CDM","278","RC","C1821","HCPCS","","","facility","both","","","","409.58","409.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Spnl Polyax Fen Cann 6.5Mm","40005049","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1762.06","1762.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Si Core 9.5Mmx60Mm","40005050","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L200Mm Dia6Mm Post","40005051","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L20Mm Post Ti","40005052","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1013.02","1013.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Opn Rev 11-14Mm","40005053","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1297.97","1297.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 2.5Cc Dbm Putty","40005054","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1000.71","1000.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 6.5Mm Peek Sz2 36In","40005055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1001.33","1001.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.2X5.5X55Mm Compr","40005056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1038.38","1038.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.2X5.5X60Mm Compr","40005057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1038.38","1038.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.7X45Mm Compr","40005058","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1024.98","1024.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7X55Mm Compr Thrd Hd","40005059","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2269.35","2269.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L90Mm Dia7Mm Thrd","40005060","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1923.85","1923.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L75Mm Dia7Mm Hdlss","40005061","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1814.95","1814.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dst R 4H St M 88Mm Ss Va-Lcp","40005062","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1863.4","1863.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X52Mm Sterile Xl25","40005063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.14","500.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5X55Mm","40005064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X100Mm","40005065","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Set Spinal Pedicle","40005066","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","445.2","445.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Acif Md 5Mm 6Deg","40005067","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia2.7Mm Ti","40005068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","255.82","255.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dst L 2H M 82Mm Ss Va-Lcp","40005069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1742.03","1742.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnal Opn-Opn Ax Rev","40005070","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1114.31","1114.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Spnl Polyax Fen Cann 5.5Mm","40005071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L500Mm Dia6Mm Post","40005072","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dissectr Us Crdls Crv Jaw 26Cm","40005073","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","941.16","941.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnal M W14Xh6Xl16Mm 6Deg","40005074","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Fib Cort","40005075","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.28","229.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Fib Cort","40005076","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.28","229.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L15Mm Dia3.5Mm Ti","40005077","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","527.56","527.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Demineralzd Ptty Osteocyte 3Cc","40005078","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","1256.1","1256.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mill Bone Bwl W/2 Blade Disp","40005079","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","547.79","547.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endoscp L200Cm","40005080","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","250.19","250.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Fib Cort","40005081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","227.12","227.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Od5Fr Blln Es Styl Extn","40005082","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","516.68","516.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40005083","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","73.51","73.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lok Im Nail Dia5Xl84Mm","40005084","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidepin Orth 27Mm Flarehawk","40005085","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","445.2","445.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl 12/14X29Mm 6Deg Shim","40005086","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4374.09","4374.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"7.5X55Mm Polyax Fen Cann Xtab","40005087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2411.82","2411.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stop Drll For 6Mm/9Mm Cann Stp","40005088","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","573.87","573.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz4 Lt Knee Cocr","40005089","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3332.64","3332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artic Fem 8-11 Tib","40005090","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L59Mm Ant Cervc 3","40005091","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X12Mm","40005092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L14Mm Od2.5Mm Ant","40005093","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone 40Gm Visc Palacos","40005094","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2191.11","2191.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surg L12Mm Dia2.4Mm Fix","40005095","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Surg L14Mm Dia2.4Mm Fix","40005096","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retriever Fb Dia8.5-10Mm 2.8Mm","40005097","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","554.53","554.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm -4Mm Offset","40005098","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1338.38","1338.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal W16.5Xl26Mm Thk2Mm","40005099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1343","1343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tunneler Sur Shaft L13.4In","40005100","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","873.74","873.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum X-Artc Dst R 8H","40005101","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2229.9","2229.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Drill Sur Sys Elite Dir","40005102","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1580","1580","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Ant Cer 3 Lev 54Mm","40005103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2149.72","2149.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14Xh7Mm D12Mm","40005104","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1812.77","1812.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Por Ti 7 Deg 7Mmx14Mmx12Mm","40005105","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3930","3930","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X35Mm Stardrv","40005106","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.28","229.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum X-Artc Dst R 8H","40005107","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 110Mm 3.5Mm Qc","40005108","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","152.19","152.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L125Mm Dia2Mm Qc","40005109","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","155.17","155.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 11Mm For Ria 2Bone","40005110","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1096.99","1096.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L124Mm Dia28X16Mm","40005111","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","12544.56","12544.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L124Mm Dia16X16Mm","40005112","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6565.3","6565.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L82Mm Dia16X16Mm","40005113","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6099.36","6099.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal L120Mm Dia3.5Mm Cerv","40005114","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Sheath Evar 10Fr L65Cm","40005115","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","2151.96","2151.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W14Xh6Mm D12Mm","40005116","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1812.77","1812.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sd 2 Ld 4.0Mmx16Mm","40005117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","494.17","494.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Sd 2 Ld 4.0Mmx12Mm","40005118","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","494.17","494.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl Sgl Ld 4Mm X 16Mm Insignia","40005119","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl Sgl Ld 4Mm X 14Mm Insignia","40005120","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl Sgl Ld 4Mm X 12Mm Insignia","40005121","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","374.37","374.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drl Sgl Ld 4Mm X 12Mm Insignia","40005122","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld 4.5Mm X 14Mm Insignia Acp","40005123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld 4.5Mm X 12Mm Insignia Acp","40005124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld 4.5Mm X 12Mm Insignia Acp","40005125","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","374.37","374.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 10Fr L220Cm Acc Chn 3.7Mm","40005126","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3013","3013","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autocap Rx Olympus Intergrated","40005127","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","53.39","53.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2Mm Aqua Ti","40005128","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","529.79","529.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia2Mm","40005129","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.83","1079.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Foot 6 H T-Shape","40005130","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1470.35","1470.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5X50Mm Polyax","40005131","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2446.57","2446.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Spinal L18Mm Ant Cerv 1Lev","40005132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Guid L230Mm Dia2.5Mm Ss","40005133","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","39.26","39.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L225Mm Dia7Mm L Hum","40005134","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2268.94","2268.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28Mm Dia4.5Mm St","40005135","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.21","427.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X32Mm Ft Blunt","40005136","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.21","427.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia10Mm St Hllw","40005137","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","497.87","497.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jrf Versagraft 3.5 Tend","40005138","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2038.2","2038.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X65Mm Lord Ticp","40005139","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X60Mm Lord Ticp","40005140","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 10-11 Tib Ef","40005141","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz E-F Fem Sz","40005142","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kex102Ebexpress Ii Ty 10/2","40005143","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3957.51","3957.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Cyto 21Ga L137Mm D1.9Mm","40005144","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","444.36","444.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver Spnl Stylt Nit Mis","40005145","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","540.92","540.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X40Mm Lord Ti","40005146","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1817","1817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 6.5Mmx55Mm Cort","40005147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1794.88","1794.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 7.5Mmx35Mm Cort","40005148","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 7.5Mmx40Mm Cort","40005149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fen Cann Screw 7.5Mmx55Mm Cort","40005150","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1816.21","1816.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Fen 10.5Mmx60Mm","40005151","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3199.01","3199.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Substitute Bne Graft 10Ml Mtrx","40005152","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3104.74","3104.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Identit Alif Sa Spcr 9X38X28Mm","40005153","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7984.45","7984.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 595Cc Dia13.1Cm","40005154","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","612.15","612.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub Gel 5Cc Dbm Fd","40005155","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","849.26","849.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 595Cc Dia13.1Cm","40005156","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Implant Med Patellofemoral","40005157","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3152.1","3152.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L24Cm D14.5Fr Insrt L19Cm","40005158","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","563.18","563.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 150Um Ball Tip","40005159","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1012.74","1012.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 200Um Ball Tip","40005160","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1001.29","1001.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 505Um Tfl Disp Slt","40005161","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1032.18","1032.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Laser 940 Mic Disp Sltv","40005162","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1229.73","1229.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Saw W12Xl90Mm Cut","40005163","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Saw W13Xl90Mm Thk1.19Mm","40005164","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","357","357","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Talar Sz 2 Thk12Mm Ank","40005165","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5380.83","5380.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia36Mm Plus 7.5Mm","40005166","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2240.88","2240.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lok Im Nail Dia5Xl46Mm","40005167","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","437.55","437.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lok Im Nail Dia5Xl50Mm","40005168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.5X14Mm","40005169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L36Mm Ant Cerv 2","40005170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.5X45Mm Polyax Fen Cann Xtab","40005171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2512.2","2512.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"6.5X50Mm Polyax Fen Cann Xtab","40005172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6071.85","6071.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X30Mm Post","40005173","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 Std R Knee","40005174","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3332.64","3332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 3-5 Tib Cd/Ps","40005175","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artic Fem 6-9 Tib Ef","40005176","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2733.15","2733.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L195Mm Dia4.5Mm Qc","40005177","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","178.71","178.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"3Sz Jos Lamelas Atr Lift Sys","40005178","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","762.99","762.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ring Annuloplasty Dia36Mm","40005179","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","297.49","297.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biocomposite Swivelock Anchr","40005180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Thk1.5Mm Orbit Teal","40005181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1823.04","1823.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nut Buttress Compr Guid Sl Tfn","40005182","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","834.71","834.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Surg Guid Yel Blade Scr","40005183","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1890.14","1890.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 10Cc Mold Demin","40005184","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","2992.43","2992.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X40Mm Lodrotic","40005185","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Otlif W9Xh17Xl26Mm","40005186","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8678.75","8678.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm Distal","40005187","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3140.45","3140.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Identiti Alif Sa Spcr 8X38X28","40005188","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7984.45","7984.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pa Fen 7.5Mmx35Mm","40005189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3017.93","3017.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cook Airwy Exchg Cath","40005190","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","175.95","175.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7Fr L130Cm Blln L40Mm","40005191","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2204.1","2204.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L52Mm 6H Bilat Ss","40005192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","686.7","686.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X11Mm Dst Rad Ft","40005193","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","197.4","197.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Cort Ft St","40005194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L221Mm Dia4.3Mm Qc","40005195","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","332.45","332.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L125Mm Dia1.5Mm","40005196","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","293.03","293.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X84Mm St Xl25 Rcss","40005197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kex152Eb-Cdsexpress Ii Ty 15/2","40005198","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","4503.23","4503.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 375Cc Dia12.8Cm","40005199","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1185","1185","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X18Mm","40005200","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.1X18Mm","40005201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L20Mm Ant Cerv 1Lev","40005202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Clav Sup R 6H 105Mm","40005203","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1285.99","1285.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast Dia12.8Cm P4Cm","40005204","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","578.76","578.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Breast Dia14Cm","40005205","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","578.76","578.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 600Cc Dia14Cm","40005206","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bio Tiss W6Xl6Cm Fet Bov","40005207","CDM","278","RC","Q4110","HCPCS","","","facility","both","","","","2706.74","2706.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 525Cc D13.9Cm P4.7Cm","40005208","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","577.5","577.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breast 545Cc Dia14Cm P4.9Cm","40005209","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","612.15","612.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone Full Dose Pmma Hi","40005210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","375.3","375.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L170Mm D10Mm Nk 125Deg","40005211","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2159.54","2159.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Fib Cort","40005212","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.79","222.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Total Ankle Sz 3 6Mm Infinity","40005213","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4531.44","4531.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Compr M For 21In Calf","40005214","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","18.54","18.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Clav Sup R 6H St 105Mm","40005215","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1428.14","1428.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L100Mm Dia1.8Mm","40005216","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","283.35","283.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X28Mm Xl25 Recess","40005217","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","437.55","437.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix Ant Cerv Intbdy Temp","40005218","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl W14Xh7Xl12Mm 7Deg","40005219","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3081","3081","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl W14Xh8Xl12Mm 7Deg","40005220","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3081","3081","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinl Cobalt 1-3 Lev 5.5Mm","40005221","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2421.71","2421.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedc 4.0Mm X 24Mm","40005222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1418.82","1418.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X26Mm Post Pedcl","40005223","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Basket Stone Remv W20Xl1900Mm","40005224","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","583.21","583.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Basket Extr Shth 7Fr L220Cm","40005225","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","378.42","378.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade L125Mm Dia10.5Mm Ns Ti","40005226","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","991.48","991.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L170Mm Dia10Mm 130Deg","40005227","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2017.66","2017.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm Cort Hex","40005228","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","848.4","848.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X34Mm Canc Cann","40005229","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","362.84","362.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Cort Hex","40005230","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.18","50.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm D10Mm Nk 130Deg","40005231","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2640.44","2640.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Suture L19.1Mm Dia5.5Mm","40005233","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1023.96","1023.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili Self 7Fr Cath 208Cm","40005234","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","270.9","270.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Por Ti 10 Deg 6Mmx18Mmx16Mm","40005235","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4165.8","4165.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X20Mm Post Pedcl","40005236","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X18Mm Post Pedcl","40005237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X24Mm Post Pedcl","40005238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X30Mm Post Pedcl","40005239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X34Mm Post Pedcl","40005240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L240Mm Dia4Mm Post","40005241","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","555.57","555.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prx L 4H St 87Mm","40005242","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2558.02","2558.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X34Mm Canc Cann","40005243","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X160Mm Can Hex","40005244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","501.38","501.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L450Mm Dia2.8Mm","40005245","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","175.63","175.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obturator Lapscp 8Mm Weck Vst","40005246","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","85.11","85.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X40Mm","40005247","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Surg L13In Std Ti","40005248","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","779.9","779.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Drv Sprpllr Tib Nail Insrt","40005249","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2993.09","2993.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X45Mm","40005250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X35Mm","40005251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X50Mm","40005252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X160Mm","40005253","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 130Mm Sz 5 Plus 44Mm","40005254","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2963.88","2963.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kirschner Wire .045 X 6In","40005255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","33.39","33.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X40Mm Va Ft Lok","40005256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","249.31","249.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Cort Ft","40005257","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.79","222.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Cort Ft","40005258","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.28","229.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lok Compr Plating Sys","40005259","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409.58","409.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 10X70Mm Ti","40005260","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4860.1","4860.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 Nrw L Cocr","40005261","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3332.64","3332.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Cd Fem 3-9","40005262","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2056.37","2056.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.5X16Mm","40005263","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.0X50Mm","40005264","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","873.6","873.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox L Sm 5 H","40005265","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3987.51","3987.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Gtr Troch Left Lg","40005266","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2960.38","2960.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Endoscp Instr Gastrc Rcssn","40005267","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1414.1","1414.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X175Mm Canc Hex","40005268","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Cort Hex","40005269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.57","53.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X28Mm Cort Hex","40005270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","54.5","54.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L150Mm Dia4Mm","40005271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","269.1","269.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Gtr Troc Lt Lg St","40005272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3072.47","3072.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox L Sm 5H St","40005273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4137.5","4137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X95Mm Canc Cann","40005274","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L135Mm D2.8Mm Calib","40005275","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","253.76","253.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X170Mm Canc Hex","40005276","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","478.59","478.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub Ptty 1Cc Allgrft","40005277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","837.09","837.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X32Mm Cort Ft","40005278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","122.66","122.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Lat Ant 10H St","40005279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1498.95","1498.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X45Mm Multiaxl","40005280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3460.56","3460.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X40Mm Multiaxl","40005281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3460.56","3460.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal L140Mm Dia5.5Mm Post","40005282","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1178.97","1178.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub Dbm 150X11Mm","40005283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","875.49","875.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L330Mm Dia12Mm Tibial","40005284","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2628.37","2628.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm St Xl25","40005285","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","627.37","627.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X35Mm Lord Ticp","40005286","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X76Mm St Xl25","40005287","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X35Mm Multiax","40005288","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2706.79","2706.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Urethral 8Fr L16In Blln","40005289","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","12.05","12.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Urethral 10Fr L16In Red","40005290","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","12.05","12.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire 1.5X1.5Mm Max Clsr 5.5Mm","40005292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1393.43","1393.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kt Drlbt Dia2Mm Drill Guide","40005293","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","798","798","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saffron Fixation Tool","40005294","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1031.42","1031.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saffron Anchor","40005295","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","140.04","140.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flux-C 3D Cerv 14X12Mm 7Mm 6Dg","40005296","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal Cerv 12X6X14Mm 6Dg","40005297","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8331.6","8331.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5Mm Dia16Mm","40005298","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113","1113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Locking Ti Strl","40005299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","649.61","649.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jada Verison 2.0","40005300","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2034.25","2034.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Iu Bakri 24Fr 54Cm Bln","40005301","CDM","278","RC","C2628","HCPCS","","","facility","both","","","","154.54","154.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox L8 H St Sm","40005302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2543.8","2543.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X60Mm Va Tib Ft","40005303","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.4","281.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L35Mm Dia5.5Mm Ti","40005304","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L40Mm Dia5.5Mm Ti","40005305","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Human Tiss Blk Achilles","40005306","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2882","2882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 16H Broad 296Mm Ss","40005307","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1455.42","1455.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L14Mm Dia4.1Mm","40005308","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L34Mm Ant Cerv 2Lev","40005309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L125Mm Dia5Mm","40005310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.28","229.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Dis Lat Rt 6H","40005311","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892.67","892.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Can Hex Drv","40005312","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.72","427.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Can T15 Drv","40005313","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","149.12","149.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L149Mm 8H R Dst Med","40005314","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3566.14","3566.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 2.7Mm Cannulated Cpl","40005315","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","513.76","513.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ortho L150Mm D1.4Mm","40005316","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","162.93","162.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occipitocervical 4.5X36Mm Plyx","40005317","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L240Mm Dia3.5Mm Crv","40005318","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","581.7","581.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl Acif Sm 14X6X12Mm","40005319","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl Acif Sm 14X7X12Mm","40005320","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb L15Cm Dia4Mm 0.02In","40005321","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1658.05","1658.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb L35Cm Dia4Mm 0.02In","40005322","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2093.5","2093.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb L12Cm Dia5Mm 0.02In","40005323","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1658.05","1658.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L100Mm Dia11Mm Mr","40005324","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","342.8","342.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix M Clp On Slf Hld","40005325","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","674.48","674.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fx L125Mm Dia11Mm Cfbr","40005326","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","342.8","342.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X100Mm Cort Hex","40005327","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","63.12","63.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L33Mm Thk1.9Mm Ant","40005328","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2982.82","2982.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Occipitocrv 4.5X24Mm","40005329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1187.21","1187.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm Sz 5 12/14 Tapr","40005330","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1591.06","1591.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"L12Cm Dia28.5Mm Leg 14.5Mm","40005331","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","20859.55","20859.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm D10Mm Nk 125Deg","40005332","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3332.83","3332.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L315Mm Dia10Mm Tib Tn","40005333","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2628.37","2628.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinl H14Mm 32X21Mm 16Deg","40005334","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","18746.1","18746.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif 32X11X21Mm","40005335","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","18746.1","18746.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L25Mm D5.5Mm Ant","40005336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X38Mm Xl25 Recess","40005337","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","513.15","513.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X35Mm Post","40005338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1830.82","1830.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L15Mm Dia4Mm Ant","40005339","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","516.43","516.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 375Cc Dia12Cm","40005340","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg 20Fr Pul Sfty En Accs","40005341","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","390.74","390.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L4Mm D1.8Mm Blu Ti","40005342","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","186.98","186.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Cblt Chrm 4 Lev 5.5Mm","40005343","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8311.87","8311.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap 4.0Mm Single-Use","40005344","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","333.9","333.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Stardrive","40005345","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","761.07","761.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Stardrive","40005346","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","746.71","746.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Gh","40005347","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt L4.5Cm Dia26Mm","40005348","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7310.98","7310.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Twister Wire L150Mm Maxillofcl","40005349","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","845.96","845.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X68Mm Canc Hex Drv","40005350","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X72Mm Canc Hex Drv","40005351","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8Mm Dia2.7Mm Cort","40005352","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","191.84","191.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm Emgcy Mtrx","40005353","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","191.84","191.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Lat L Cs3 St Ss","40005354","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2106.46","2106.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L110Mm Dia2Mm Calib","40005355","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rad Dst Dors 3X5 H","40005356","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1110.55","1110.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L28Mm Dia3.5Mm","40005357","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L30Mm Dia3.5Mm","40005358","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Sz 4 Rod To Rod","40005359","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1817","1817","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 10 H 1/3 Tblr 117Mm","40005360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","340.58","340.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acif Sm 14X5X12Mm","40005361","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1972.91","1972.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Monitoring","40005362","CDM","360","RC","95940","HCPCS","","","facility","both","","","","340","340","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L60Mm Od3.5Mm Ns","40005363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","65.75","65.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cv 6Fr Polyur 2 Lumn Peel","40005364","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","628.86","628.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Mtcrpl Dors 29Mm Ss","40005365","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","968.3","968.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox Rt 14H Sm","40005366","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2629.18","2629.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L55Mm Dia3.5Mm Smth","40005367","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L45Mm Thk1.9Mm Ant","40005368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3281.57","3281.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"No2 4.5X36Mm Polyax 2 Ld","40005369","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artic Tib Gh Fem 7-12","40005370","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artic Tib Cd Fem 3-9","40005371","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2179.75","2179.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone W14Xh5Xl14Mm Canc","40005372","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1771.94","1771.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tibia Prox R 14H St","40005373","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2851.63","2851.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox R Sm 5H St","40005374","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4385.75","4385.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaft Scrwdrvr T4 Stardrv Self","40005375","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","806.86","806.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L180Mm Dia3.5Mm Cort","40005376","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","326.34","326.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"No2 4.5X32Mm Polyax 2 Ld","40005377","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dart-Fire Edge Screw 3.5Mm Hd","40005378","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","243.61","243.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx30Mm","40005379","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx34Mm","40005380","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx44Mm","40005381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Med Lat No1 3.5X12Mm","40005382","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Med Lat No1 3.5X14Mm","40005383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L Std Volar Dst Rad","40005384","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1717.46","1717.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R Std Volar Dst Rad","40005385","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1820.51","1820.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shldr Stbl Lmb Pos Tenet T-Max","40005386","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","175.54","175.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Conn Lng Cann Insrt Hndl","40005387","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1052.91","1052.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Cerv Vrtbr 4X42Mm","40005388","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5928.35","5928.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 2X310Mm Rnd Trocar","40005389","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","117.23","117.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Shrt 3.5X36Mm Hdlss","40005390","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx38Mm","40005391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L255Mm Dia7Mm R Hum","40005392","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2268.94","2268.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X30Mm Cort Hex","40005393","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.6","96.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 5 H Crv 74.5Mm","40005394","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","935.55","935.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne 2.7X44Mm T10 Drive Ft","40005395","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.44","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X50Mm T10 Drv Ft","40005396","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.44","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L135Mm Dia2Mm Scaled","40005397","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","275.8","275.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L122Mm Dia2.7Mm Add","40005398","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","275.8","275.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pusher Knot Sut Cut Portal Skd","40005399","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","489.72","489.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X34Mm St Hum","40005400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","416.26","416.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X24Mm Hum Ft Lok","40005401","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.78","256.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealant Tiss 4Ml Purify Bovine","40005402","CDM","270","RC","C9250","HCPCS","","","facility","both","","","","1211.54","1211.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3Mm Rnd","40005403","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1676.74","1676.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Cobalt 4+ Lev 3.5Mm","40005404","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","8389.7","8389.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shaver L11Cm Dia2Mm","40005405","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1671.34","1671.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cann Endoscp Dia15Mm Trcr","40005406","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","52.99","52.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Endoscp Dia11.5Mm Cann","40005407","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","44.54","44.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Endoscp Dia5.5Mm Thor","40005408","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","50.88","50.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Endoscp Od10.5Mm Cann","40005409","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","51.36","51.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32Mm Hex Drv","40005410","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.77","240.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3X3 H T Plt 50Mm","40005411","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","601.25","601.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4X6 Ht Plt L78Mm R","40005412","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.04","800.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5 H Str 70Mm Ss Sm","40005413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","772.09","772.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 H Str 84Mm Ss Sm","40005414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","946.78","946.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx40Mm","40005415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx46Mm","40005416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dart-Fire 3.5Mmx50Mm","40005417","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","896.99","896.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Dart-Fire 4Mmx50Mm","40005418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","895.44","895.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia9Mm Tib Tn","40005419","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2628.37","2628.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X38Mm Hex Drv","40005420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X36Mm Cort Hex Hd","40005421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X58Mm Cort Hex Hd","40005422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X56Mm Cort Hex Hd","40005423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X44Mm Cort Hex Hd","40005424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm Cort Hex Hd","40005425","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X42Mm Cort Hex Hd","40005426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","240.76","240.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X74Mm St Xl25 Rcss","40005427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","591.86","591.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X34Mm Post Pedcl","40005428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.82","1456.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Pedcl Crv 5Mmx34Mm","40005429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1348.91","1348.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Pedcl Crv 5Mmx36Mm","40005430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1348.91","1348.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X52Mm St Xl25 Rcss","40005431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","627.37","627.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia10Mm R Fem","40005432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3113.45","3113.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prosthesis Penile 100Ml Pc","40005433","CDM","278","RC","C1813","HCPCS","","","facility","both","","","","4533.78","4533.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit Occipital Str 4.5Mm","40005434","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","311.64","311.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicl 3.5Mmx16Mm","40005435","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1348.91","1348.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedicl 3.5Mmx14Mm","40005436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1348.91","1348.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Occptl Ti 4.5Mmx10Mm","40005437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","538.69","538.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Occptl Ti 4.5Mmx8Mm","40005438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","538.69","538.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occipital Tulip Alph","40005439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","921.14","921.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occipital Plate 56Mm","40005440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4862.62","4862.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hinged Rod 4.0Mm Cran 4.0Mm","40005441","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1519.88","1519.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura W1Xl1In","40005442","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","819.17","819.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ortho L18In Dia1.2Mm","40005443","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","128.24","128.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Ortho L12In Od2.4Mm","40005444","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","178.84","178.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L25Mm Dia11Mm Ant","40005445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedcl 5Mmx26Mm","40005446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedcl 5Mmx28Mm","40005447","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X28Mm Post Crv","40005448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X105Mm Stardrv","40005449","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","952.06","952.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia7.5Mm Cort","40005450","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1407.57","1407.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L50Mm Dia7.5Mm Cort","40005451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1407.57","1407.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Cerv Ti 4.0Mmx60Mm","40005452","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X36Mm","40005453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Top Ld Scrw Top","40005454","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1800.41","1800.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 3.5X200Mm Post","40005455","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Bne Sub Dbm Crush Mix 5Cc","40005456","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","3314.3","3314.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 7 L109Mm 12/14","40005457","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3235.7","3235.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 3.5Mm Cann","40005458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 4Mm Cann","40005459","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","108.72","108.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 4.5Mm Cann","40005460","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 5.5Mm Cann","40005461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 6.5Mm Cann","40005462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 7.5Mm Cann","40005463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Intrathecl L114Cm Ascenda","40005464","CDM","278","RC","C1755","HCPCS","","","facility","both","","","","2019.24","2019.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X42Mm Stardrv","40005465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","761.07","761.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng27522Ux Onyx","40005466","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 4.75Mm Regenesorb","40005467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","766.5","766.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W17Xh7Xl14Mm 6Deg","40005468","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3925.57","3925.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Radial 7.5Mm +4 Univ Head","40005469","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3645.08","3645.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Rad Dia24Mm +2Mm Offset","40005470","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3091.02","3091.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Natural Matrix Protiens Fibers","40005471","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","10769.58","10769.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Dil Balloon L16Mm Dia6Mm","40005472","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","2633.1","2633.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Infl For Snus Eustachian","40005473","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","196.07","196.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.3X10Mm Cort","40005474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","177.55","177.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spinl L 30X39Mm 11Deg","40005475","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6606.33","6606.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endplate Spnl M 28X34.5Mm 11Dg","40005476","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6606.33","6606.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 1 H St Spr Ss Lp","40005477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","493.71","493.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Polyaxial Screw 40 X 16Mm","40005478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Polyaxial Screw 40 X 28","40005479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Cort Hex","40005480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.84","82.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X80Mm Cort Hex","40005481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.84","82.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Pelvc 10H Crv 154.5Mm","40005482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","972.17","972.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Infrapectineal R Lg","40005483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2163.34","2163.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Half Pin Fix L180Mm Dia5Mm","40005484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","249.16","249.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X14Mm Va St Ti","40005485","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.25","278.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Pk2 Sa Sd 3.5Mm X 16Mm","40005486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1005.55","1005.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ntrl Mtrx Protiens Fibers Lng","40005487","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","7186.16","7186.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Radial Dia20Mm Cocr Std","40005488","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2916.06","2916.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm Va T8","40005489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","245.78","245.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ti L8Mm Od3.5Mm","40005490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","378.42","378.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L150Mm Dia1.4Mm","40005491","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","840.59","840.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L145Mm Dia2.7Mm Cann","40005492","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1000.54","1000.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Lcp 2Mm 6Hole 45Mm","40005493","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","461.12","461.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl No2 4.5X28Mm Polyax","40005494","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1443.33","1443.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.4Mm Adjustable","40005495","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plat Bn Clav Lat Rt Cs3 Va Lcp","40005496","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2106.46","2106.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L38Mm Ant Cerv 2","40005497","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Rt Lat Menis","40005498","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","6550","6550","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Laryn 1Ml Gel H2O Base","40005499","CDM","278","RC","C1878","HCPCS","","","facility","both","","","","1138.86","1138.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X30Mm Pedcl","40005500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1416.26","1416.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Lcp 2Mm 6Hole 45Mm","40005501","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","488.79","488.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X75Mm Cntour Dnl","40005502","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","381.04","381.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.5X12Mm","40005503","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 9Mm Mini Shldr Cocr","40005504","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5135","5135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X46Mm Tib Cort","40005505","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.34","47.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X50Mm Tib Cort","40005506","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.76","48.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Otlif W9Xh17Xl24Mm","40005507","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8187.5","8187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss 3.5X260 Gracils","40005508","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brace Tele Rang Pst Op Univ","40005509","CDM","270","RC","L1832","HCPCS","","","facility","both","","","","240.24","240.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X50Mm Post","40005510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1855.06","1855.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal 34X26X15Mm 15Deg","40005511","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6248.7","6248.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacr Spinl Alif W34Xh17Xl26Mm","40005512","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6248.7","6248.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 15Mm 15Deg Alif 0","40005513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4860.1","4860.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 17Mm 20Deg Alif 0","40005514","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4860.1","4860.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spnl Xsm 41-56Mm Rod","40005515","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1106","1106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X3 H St Std 22X54Mm Ss","40005516","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1410.9","1410.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 1St Mt R Sm 42Mm","40005517","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3599.25","3599.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evr Stnt L12Cm D20X14.5Mm","40005518","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","20859.55","20859.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 11.5Mm","40005519","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1097.83","1097.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 12.5Mm","40005520","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1035.69","1035.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum Ext Med Dst R 1H","40005521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1751.84","1751.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.5X95Mm Stardrive","40005522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","952.06","952.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X66Mm Xl25 Recess","40005523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.5X130Mm Stardrive","40005524","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","952.06","952.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizr Stem L120Mm Dia13Mm","40005525","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","193.2","193.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 7 L133Mm Nk L36Mm","40005526","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2701.8","2701.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Coag L3Cm Minimally","40005527","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","16285.92","16285.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X55Mm Post","40005528","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1884.15","1884.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod 5.5Mm Len 100Mm Curved Ti","40005529","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Vbr 16X13Mm 5Deg Oval","40005530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3374.3","3374.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Iab Rdgrd Od8 Fr 40Ml Flx","40005531","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","1197.48","1197.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sonable Insertion Pack","40005532","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X40Mm","40005533","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"L20Mm 1 Stp Osteo Intro W/ Cds","40005534","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","4248.33","4248.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X50Mm Compr Hdlss","40005535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fens Cann Pa Screw 7.5Mmx45Mm","40005536","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1790.14","1790.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fens Cann Pa Screw 7.5Mmx50Mm","40005537","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fens Cann Pa Screw 8.5Mmx50Mm","40005538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal W10Xh8Xl25Mm 5Deg","40005539","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3182.81","3182.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Compr Hdlss","40005540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","794.68","794.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Cerv 3.5X14Mm Slf","40005541","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","434.07","434.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang Ml 4.5Mmx30Mm Invictus Ct","40005542","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1272.56","1272.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hern Xl W7.7Xl9.7In","40005543","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2512.2","2512.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X45Mm Star Drv Ft","40005544","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","943.82","943.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Clsr 35Mm Atrclip Pro2","40005545","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5814.1","5814.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Esurg 6.1Cm Isltr Sng Rt","40005546","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","5554.4","5554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Comprn Hdlss","40005547","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","804.3","804.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pa Fen 7.5Mmx50Mm","40005548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3198.87","3198.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X7 H St Xln Std","40005549","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2428.46","2428.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70Mm Star 25 Drv","40005550","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","785.4","785.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Idntiti Alif Sa Spcr 8X38X28Mm","40005551","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7860","7860","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L105Mm 4 H Prox Med","40005552","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1454.11","1454.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X40Mm Xl25 Recess","40005553","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L145Mm Dia3.2Mm 3 Flut","40005554","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","278.56","278.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt L12Cm D20X12Mm","40005555","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","19678.82","19678.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intr 15Fr L33Cm Od5.6Mm","40005556","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","1222.92","1222.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X3 H Nar 19.5X51Mm Ss","40005557","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1262.42","1262.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Valor Ti L20Mm Od5Mm","40005558","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","943.82","943.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X36Mm Hum Thrd","40005559","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","353.93","353.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X40Mm Hum Thrd","40005560","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","353.93","353.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X150Mm Cort Hex","40005561","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","159.77","159.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L36Mm Dia9Mm Rt Fem Ti","40005562","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2937.22","2937.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L240Mm Dia8.5Mm R Hum","40005563","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2268.94","2268.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L34Mm Std Lev 2","40005564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1423.58","1423.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Od8Mm Im Step","40005565","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","457.44","457.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal L130Mm Dia5.5Mm Post","40005566","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal L500Mm Dia6Mm S Post","40005567","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","467.96","467.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X50Mm","40005568","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6248.7","6248.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ti Nut","40005569","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1046.75","1046.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Pedicle 6X120X90Mm","40005570","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4790.67","4790.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L15Mm Ibt Osteo Intro Kyphon","40005571","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","5278.07","5278.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X65Mm Fib Cort","40005572","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","269.35","269.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Biologic 2X9Cm Bov Prcrd","40005573","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","573.48","573.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Cath 15Mm Od1.9Mm","40005574","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","192.36","192.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Cath 15Mm Od1.9Mm","40005575","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","186.78","186.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X40Mm Tib Cort","40005576","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","58.4","58.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3X7 H T 87Mm R","40005577","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","930.3","930.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orsiro Mission Dia3.5Mm L40Mm","40005578","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kntlss Tensiontight Bttn Insrt","40005579","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1382.5","1382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh8.5Xl28Mm","40005580","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11114.04","11114.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh10.5Xl28Mm","40005581","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11499.18","11499.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh10.5Xl28Mm","40005582","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11444.16","11444.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L175Mm Dia4Mm","40005583","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","198.79","198.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med 40Mm Hoopless End","40005584","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","5059.88","5059.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X55Mm","40005585","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5X50Mm","40005586","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2175.66","2175.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 9.5X90Mm","40005587","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 8.5X90Mm","40005588","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X350Mm","40005589","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl L30Mm Post Lat","40005590","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1172.36","1172.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl Rod Para Opn","40005591","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1172.36","1172.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X40Mm Canc Cann Lng","40005592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Battery Drvr Disp Dd-Matrixpro","40005593","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","899.3","899.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 18 H R Rib 8 9 Rose","40005594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2734.63","2734.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 17 H Ti Precontoured","40005595","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2734.63","2734.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 16 H R Rib 4 5 Rose","40005596","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2734.63","2734.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L11Mm Dia2.7Mm Ti","40005597","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","579.05","579.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Rm L1150Mm D3Mm 3.8Mm Ball","40005598","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","403.98","403.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Endoscp Triang Ang","40005599","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","455.78","455.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Endoscp Hk Ang For Ectr","40005600","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","455.78","455.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern L W4Xl6In R Inguinal","40005601","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","561.03","561.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drillable Bone Void Filler 5Cc","40005602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5234.87","5234.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Syn Cem W/ Gent 10Ml Cer","40005603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","10328.41","10328.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Surg Dia10Mm Univ Str","40005604","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","6792.58","6792.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Dst Tib","40005605","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.93","48.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W30Xl30Cm Polyglactn","40005606","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2841.39","2841.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm Dia9Mm Nk 130Dg","40005607","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2138.75","2138.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 14Mm Mini Shldr Cocr","40005608","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4512.95","4512.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orsiro Mission Dia2.5Mm L13Mm","40005609","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instr Dia1.5Mm Straight Soft","40005610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L56Mm Ant Cerv 3","40005611","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib L 80Mm Wdg Knee","40005612","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1113","1113","","","","","","","","","","","","","Gross Charge Type: Standard"
"14X80X48X11X8.8Mm Knee 0.8Gm","40005613","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2930.9","2930.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"74X56.3X11.5X14Mm Knee 1.2Gm","40005614","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2930.9","2930.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Stem Extn L100Mm 12X8Mm","40005615","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 3.8Mm Slim","40005616","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 5Mm Regular Sgl","40005617","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","630","630","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 5.8Mm Large Sgl","40005618","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","714","714","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm Cort Hex","40005619","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.19","50.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Insrt 17Ga Spnl Ndl 1.1Mm","40005620","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","489.72","489.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Cort Hex Drv","40005621","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","81.11","81.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L300Mm Dia5.5Mm Z","40005622","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","477.32","477.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Ant Cer 1 Lev 17Mm","40005623","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2381.04","2381.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L110Cm L30Mm Dia8Mm","40005624","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","4519.5","4519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L135Cm L60Mm Dia8Mm","40005625","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","4519.5","4519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Cort Hex Drv","40005626","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","81.11","81.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm Dia9Mm Nk","40005627","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2631.15","2631.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur W4Xl6In Ellipse","40005628","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Sur 50Mm Std Hd Artc","40005629","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Med L 4H 93Mm","40005630","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2010.5","2010.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L72Mm Dia5Mm Ti","40005631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","331.9","331.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L77Mm Dia5Mm Ti","40005632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","331.9","331.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X46Mm Cort Hex","40005633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","56.25","56.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5Deg Short W/Screw","40005634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5155.68","5155.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Bone L18Mm W1.8Xl14Mm","40005635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4310.21","4310.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14Mm Dia3Mm","40005636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","614.46","614.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia3Mm","40005637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","613.2","613.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16Mm Dia3Mm","40005638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","623.28","623.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L13Mm Dia3Mm","40005639","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","802.48","802.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"General Staple Plate Sharps","40005640","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2440.84","2440.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Occipital Md 90Deg Ti","40005641","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1004.88","1004.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Occipital Md Ti","40005642","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6288","6288","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.5X8Mm Multiaxial St Ti Perla","40005643","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","979.44","979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.5X10Mm Multiaxial St Ti Perl","40005644","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","979.44","979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.5X12Mm Multiaxial St Ti Perl","40005645","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","979.44","979.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 4.5X12Mm","40005646","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W14Xh11Xl6Mm Peek","40005647","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1797.95","1797.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L 14Mm Cann Qc For Frn","40005648","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","999.08","999.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X60Mm Dst Tib","40005649","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.28","49.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acss W16Xh7Xl14Mm","40005650","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","48.79","48.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Canc Cann","40005651","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3265.86","3265.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X52Mm Canc Cann","40005652","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X16Mm Thrd Lok Ti","40005653","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X18Mm Locking Ti","40005654","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","333.9","333.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X14Mm Locking Ti","40005655","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","389.55","389.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2Mm Long Calib","40005656","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","389.55","389.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R Dst Fblr 5H Lok Ti","40005657","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.86","244.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syndesmosis W/ Drl Guid 3.7Mm","40005658","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1172.36","1172.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L240Mm Dia10Mm Dst","40005659","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2503.83","2503.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Ank Cort","40005660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","218.15","218.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X12Mm Va Ank Lok","40005661","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","311.64","311.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X44Mm Va T25 Strdrv","40005662","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X24Mm Va T25 Strdrv","40005663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.14","396.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X42Mm Va T25 Strdrv","40005664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","371.7","371.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Dst Tib","40005665","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.36","77.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X105Mm Recon Fem","40005666","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","407.65","407.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drillable Bne Void Filler 10Cc","40005667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7494.51","7494.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr 10X30Mm Biocompste","40005668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Accs 120Mm Obt 12Mm","40005669","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","294.87","294.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Accs Prt 5X120Mm","40005670","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","280.12","280.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Port Accs L120Mm 8Mm Lp Obt","40005671","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","281.13","281.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X40Mm Hextstar","40005672","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","737.03","737.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endo L450Cm D0.035In","40005673","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","313.16","313.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Cath L84Cm Od2.2Mm Id1.8Mm","40005674","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","1207.63","1207.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Dst Tib","40005675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","455.91","455.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 3-5 Tib","40005676","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2288.75","2288.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X36Mm Canc Hex Drv","40005677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","380.65","380.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Canc Cann","40005678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.47","373.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnal W17Xh5Mm D14Mm 7Deg","40005679","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4873.99","4873.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 X 16Mm Cervical Cage Screw","40005680","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","868.14","868.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh6.5Xl28Mm","40005681","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11381.28","11381.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Pin L100Mm D1.5Mm K Wire","40005682","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L15Mm Dia4.75Mm","40005683","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","724.5","724.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L65Mm Dia5.5Mm Lng","40005684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","380.65","380.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L7In Od4.5Mm Id2.4Mm","40005685","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","283.5","283.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5X40Mm","40005686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2260.98","2260.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5X40Mm","40005687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2196.99","2196.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X100Mm","40005688","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crossconnector Spinal L43-55Mm","40005689","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Ureth 18Fr L16In 30Cc","40005690","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","65.88","65.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L220Mm Dia1.6Mm","40005691","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","286.49","286.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ank 3D Sz 1 Tot Infin","40005692","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11371.25","11371.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Bn L160-180Mm D4-6Mm Semi","40005693","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1668.48","1668.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Va Tib Ft","40005694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","296.06","296.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm Dst Tib","40005695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.74","50.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Dst Tib","40005696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.31","50.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Dst Tib","40005697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.52","50.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm Dst Tib","40005698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.2","50.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Dst Tib","40005699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.58","50.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm Dst Tib","40005700","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.77","49.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X72Mm Canc Hex","40005701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","387.35","387.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drillable Bone Void Filler 3Cc","40005702","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2110.92","2110.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Sup Ant 5H 94Mm","40005703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1347.56","1347.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L150Mm Dia1.6Mm","40005704","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","61.52","61.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Std 2X6Mm Cort Ft","40005705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","84.34","84.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X30Mm","40005706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1490.26","1490.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal Oct 4X80Mm Post Lord","40005707","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spnl Lg 3.5/4Mm Post","40005708","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1800.41","1800.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L70Mm Dia5.5Mm Yel Ti","40005709","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spnal Sm 53-68Mm Rod","40005710","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1172.36","1172.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Polyax 6.5Mmx45Mm","40005711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2014.5","2014.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub Crush Chip 15Cc","40005712","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3508.18","3508.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L40Mm Dia5.5Mm Ti","40005713","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","691.93","691.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cross Conn Spinal L35Mm Dia4Mm","40005714","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1070.36","1070.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl Alif 7X38X28Mm 15Deg","40005715","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7532.5","7532.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia6.5Mm","40005716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1609.56","1609.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L45Mm Dia7.5Mm","40005717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1706.13","1706.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Dia7.5Mm","40005718","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1706.13","1706.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Ant Crv 2 Lev 32Mm","40005719","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1791.45","1791.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L65Mm Dia5.5Mm Post","40005720","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.04","496.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 5Cc Demin Fbr","40005721","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2710.02","2710.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Ant Cerv 20Mm 1 L","40005722","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1791.45","1791.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Gtr Troch R Sm St","40005723","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3197.53","3197.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox R 8H St Ss","40005724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4336.6","4336.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Va Tib Ft","40005725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","251.54","251.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Va Tib Ft","40005726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","246.79","246.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm Dia10Mm 130Deg","40005727","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2490.97","2490.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty Sz 2 Blln L15Mm Bn","40005728","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3957.51","3957.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Lord Crv W18 H07 7","40005729","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4512.95","4512.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Ant Cerv 4.1X18Mm","40005730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","534.24","534.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Cerv Ant 42Mm 2Lev","40005731","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X36Mm Compr Hdlss","40005732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","853.61","853.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L400Mm Lng Thrd Mr","40005733","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","157.58","157.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L350Mm Lng Thrd Mr","40005734","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","154.54","154.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L300Mm Lng Thrd Mr","40005735","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","154.54","154.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L250Mm Dia2.8Mm L95Mm","40005736","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","197.11","197.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W12Xl142Mm Thk3.7Mm","40005737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2313.31","2313.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"K-Wire Blunt Nitinol","40005738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","216.47","216.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox R 12 H St","40005739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3111.07","3111.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal W10Xh8.5Xl24Mm 7-12Deg","40005740","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11004","11004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal W10X58.5Xl24Mm Forza Xp","40005741","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11004","11004","","","","","","","","","","","","","Gross Charge Type: Standard"
"8.5X45Mm Polyax Fen Cann Xtab","40005743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2512.2","2512.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X36Mm Tib Cort Ft","40005744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","50.26","50.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X38Mm Tib Cort Ft","40005745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.34","47.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X42Mm Tib Cort Ft","40005746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.76","48.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal L57Mm Thk1.9Mm Ant","40005747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2232.54","2232.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.25X150Mm Sgl End Smth","40005748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","23.15","23.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X12Mm Hnd/Ft Cann","40005749","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","715.21","715.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.1Mm Cann Add","40005750","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","467.46","467.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L41Mm 2X5 H T Shp","40005751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1966.05","1966.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X10Mm T8 Drv Ft","40005752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.72","427.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X12Mm T8 Drv Ft","40005753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.72","427.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X11Mm T8 Drv Ft","40005754","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","350.6","350.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X12Mm T8 Drv Ft","40005755","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.1","250.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X14Mm T8 Drv Ft","40005756","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.1","250.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L105Mm Dia2Mm Add","40005757","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","560.07","560.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.2X65Mm Smth Trcr Tip","40005758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","337.37","337.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X65Mm Cort Ft St","40005759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.06","78.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Hex Hd Can","40005760","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","347.26","347.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst Dia11.8Cm P2.9Cm","40005761","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1507.32","1507.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 12 Std R Knee","40005762","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 7-12 Tib Gh","40005763","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1204.61","1204.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X28Mm Post Pdcl","40005764","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X34Mm Cort Hex","40005765","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.01","49.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone 40Gm Lo Visc","40005766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X68Mm Canc Cann","40005767","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W14Xh11Xl5Mm Peek","40005768","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1835.45","1835.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X60Mm Compr Canc","40005769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1906.74","1906.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X65Mm Compr Canc","40005770","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2021.14","2021.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Saw 7Mm Narrow","40005771","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","529.2","529.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endo L7Cm Dia14.5Mm Int","40005772","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4951.75","4951.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Od14.5Mm L10Cm","40005773","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","16737.87","16737.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 99Mm Nk 30Mm Sz 2","40005774","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3471.5","3471.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 40Mm Std 2","40005775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1423.58","1423.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum Lat Dst L 7 H St","40005776","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1809.46","1809.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X115Mm Canc Hex","40005777","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","109.17","109.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L340Mm Dia3.2Mm St 3","40005778","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","367.48","367.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L40Mm Dia6Mm","40005779","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1834","1834","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L60Mm Dia6Mm","40005780","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1834","1834","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L40Mm Dia7Mm","40005781","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1834","1834","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L60Mm Dia7Mm","40005782","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","1834","1834","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L40Mm Dia9Mm","40005783","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2227","2227","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L40Mm Dia10Mm Shth","40005784","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3537","3537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L80Mm Dia10Mm","40005785","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3537","3537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X38Mm Dst Tib","40005786","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","837.27","837.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X110Mm Pelv Cort","40005787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","65.76","65.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Cerv Ant 20Mm 1Lev","40005788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2076.75","2076.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-11 13Mm R Fix Bear Cr Vivact","40005789","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1897.63","1897.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L28Mm Dia4Mm Smooth","40005790","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1937.74","1937.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L25Mm Dia3.5Mm Cerv","40005791","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","616.6","616.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 14 L140Mm Nk L38.5Mm","40005792","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3235.7","3235.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Uplr Sz +0Mm 12/14 Artc","40005793","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","332","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Harvester Endoscp Ves Incl Dsc","40005794","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1309.5","1309.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc Artfcl H6Mm 17X17Mm Ti Ha","40005795","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7498.44","7498.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Var 3.5Mm X 30Mm Invictus Ct","40005796","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1070.36","1070.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 18Mm 1 Lev","40005797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1791.45","1791.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4X18Mm St Va Sgl Ld","40005798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","396.83","396.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Crv Ti Lrd 3.5Mmx40Mm","40005799","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 3 Lev 52Mm","40005800","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2149.72","2149.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Midsubstance 4.75Mm Swivelock","40005801","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1877.45","1877.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern L 4X6In L Polypr Opn","40005802","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","555.55","555.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox R 2 H Ss","40005803","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3132.19","3132.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 H Lok Attch Ss","40005804","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1294.97","1294.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Conn Ss Stardrv","40005805","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","306.33","306.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W14Xh11Xl7Mm Peek","40005806","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1800.16","1800.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"H13Mm R Knee Vivacit-E Constrn","40005807","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2288.75","2288.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif  3 Deg 11Mm","40005808","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","19564.85","19564.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif 5Mm X 25Mm","40005809","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","489.51","489.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Dia7Mm Flx Digitorum Lngs","40005810","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2075.96","2075.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X30Mm Compr Hdlss","40005811","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X28Mm Compr Hdlss","40005812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","853.61","853.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X20Mm Compr Hdlss","40005813","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","853.61","853.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X26Mm Stardrv Recs","40005814","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","761.07","761.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washr Orth St For 4Mm Cann Scr","40005815","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","111.12","111.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X130Mm Compr Hdl","40005816","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1082.12","1082.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X30Mm Xl25 Recess","40005817","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"L5Cm 3.2Mm Cmptbl Scp Wrk Chn","40005818","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L7Cm 3.2Mm Cmptbl Scp Wrk Chn","40005819","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L9Cm 3.2Mm Cmptbl Scp Wrk Chn","40005820","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L15Cm 3.2Mm Cmptbl Scp Wrk Chn","40005821","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L12Cm 3.2Mm Cmptbl Scp Wrk Chn","40005822","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L9Cm 4.2Mm Cmptbl Scp Wrk Chn","40005823","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L12Cm 4.2Mm Cmptbl Scp Wrk Chn","40005824","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","266.18","266.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drain Lck Pig 8Fr X 25Cm","40005825","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","201.21","201.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Wrist 11 Hole Steri","40005826","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2597.36","2597.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"159Mm Ss Va-Lcp Periartc Plate","40005827","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2388.26","2388.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L150Cm Gwire 0.014In","40005828","CDM","278","RC","C1753","HCPCS","","","facility","both","","","","1303.5","1303.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X60Mm Stardrv","40005829","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X60Mm Stardrv","40005830","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia9Mm Dst Bend","40005831","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3140.45","3140.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 9 H Ti Med Clmn","40005832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4504.62","4504.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm Ft Cort Ft","40005833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X38Mm Ft Cort Ft","40005834","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Ft Cort Ft","40005835","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X48Mm Ft Cort Ft","40005836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","442.97","442.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ft L Sm Ortholoc 3Di","40005837","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2942.28","2942.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X22Mm Compr Ft Hd","40005838","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","529.79","529.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer Dia10Mm Flx Valor","40005839","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","656.88","656.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 2.5X150Mm For Ortholoc","40005840","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.2","118.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur L9Cm Dia25.4Mm Dmnd","40005841","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","343.41","343.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Impl 9Mm Incld Quadpro","40005842","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2849.25","2849.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X55Mm Canc Hex Drv","40005843","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.51","403.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Canc Hex Drv","40005844","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","427.72","427.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm T10 Drv Ft","40005845","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.44","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm T10 Drv Ft","40005846","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.44","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L135Mm Dia2.6Mm Scld","40005847","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","260.19","260.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L150Mm Dia1.4Mm","40005848","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","291.06","291.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X48Mm T10 Drv Ft","40005849","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.44","259.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Colon L90Mm Dia22Mm Anch","40005850","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3267.63","3267.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Canc Hex Drv","40005851","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","43.8","43.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W10Xh8.5Xl28Mm","40005852","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","11334.12","11334.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handle Drvr Lg Cann Qc W/ Jwl","40005853","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2495.74","2495.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.5X95Mm Stardrv","40005854","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X80Mm Stardrv","40005855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Fbrstck Fbrwr Sz 2-0 L50In","40005856","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm D12Mm Dst Bend","40005857","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3021.94","3021.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Extn 10Mm Ti Ally","40005858","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","475.74","475.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphoplasty Sz 3 Cem Gun","40005859","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","686.7","686.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"11Mm L Fix Bear Cr Vivacit","40005860","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2288.75","2288.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"14Mm R Fix Bear Constrn Ps","40005861","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Thromctmy Cath 100Cm Htorq","40005862","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","12798.7","12798.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L100Mm Dia16Mm","40005863","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2962.5","2962.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"H10Mm L Knee Polyeth Cr Fix","40005864","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1204.59","1204.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Ti 15Mm X 13Mm X 7Mm","40005865","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Ti 17Mm X 14Mm X 7Mm","40005866","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Screw 3.5Mmx16Mm","40005867","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L45Mm Dia6.5Mm Post","40005868","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1609.56","1609.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X45Mm Post Ped","40005869","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1706.13","1706.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 5.5X45Mm Post Ped","40005870","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1706.13","1706.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L300Mm Dia6Mm Post","40005871","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","637.77","637.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X45Mm Dst Tib","40005872","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.77","49.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X8Mm Va Dst Rad","40005873","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","302.74","302.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L9Mm Dia2.4Mm","40005874","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","218.4","218.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut W/ Drl Pin Btb","40005875","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Distr L14Mm Slf Drll Caspr","40005876","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","92.05","92.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Distr L16Mm Slf Drll Caspr","40005877","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","92.05","92.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Distr L12Mm Slf Drll Caspr","40005878","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","93.84","93.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox R 6 H Sm","40005879","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2177.24","2177.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox R 6H St Sm","40005880","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2379.89","2379.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Cerv Ant 18Mm 1Lev","40005881","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1959.2","1959.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L145Mm 5 H R Prox","40005882","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2282.66","2282.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia9Mm Dst Bend","40005883","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2962.69","2962.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X86Mm Lok","40005884","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal Crvd Ti 5.5Mm X 80Mm","40005885","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","546","546","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Cerv Ant 56Mm 3Lev","40005886","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1959.2","1959.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 7 Std R Cr","40005887","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","11385.76","11385.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem 13X135Mm 3Mm","40005888","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4154.8","4154.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz F R Cem Fix","40005889","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4074.91","4074.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extension Stem 12X135Mm 3Mm","40005890","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4154.8","4154.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Block Tib Sz Ef Thk10Mm Rt Med","40005891","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3235.22","3235.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Pat Lag Cann","40005892","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc R Sm Std","40005893","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3156.29","3156.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc R Sm Ext","40005894","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3282.65","3282.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc L Sm Std","40005895","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3156.29","3156.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc L Sm Ext","40005896","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3282.65","3282.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 103Mm Sz 4 Std Offset","40005897","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3373.25","3373.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L70Mm Dia5Mm Lok Lp","40005898","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.3X10Mm T4 Stardrv","40005899","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","238.18","238.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instr Bne Plating Sys Motoband","40005900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1607.81","1607.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmr 18Mm Cup Cone Mpj Motoband","40005901","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","756","756","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Sw W13Xl90Mm Thk1.27Mm","40005902","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","170.95","170.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Sw W10Xl70Mm Thk1/1.19Mm","40005903","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","149.91","149.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne 6 H Crv 78Mm Rad 88Mm","40005904","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","837.67","837.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L60Mm Dia16Mm Del","40005905","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3047.75","3047.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orsiro Mission Dia2.75Mm L22Mm","40005906","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tmplt Ant Va Lok Pat Plating","40005907","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","442.26","442.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fav Ang 9.5Mmx100Mm","40005908","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3199.01","3199.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 107Mm Sz 6 Std Offset","40005909","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3373.25","3373.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal L25Mm Thk1.9Mm Ant","40005910","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2168.87","2168.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal 14X11X8Mm Cerv","40005911","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1870.75","1870.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spnl Sm 3.5/4Mm Post","40005912","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1800.41","1800.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L30Mm Dia7Mm Cath L57Cm","40005913","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3844.16","3844.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 580Cc D13.8Cm 5.5Cm","40005914","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","577.5","577.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Temp Fix Olv Fr Dynabunion","40005915","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","219.29","219.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.6Mm Motoband Cp Dyna","40005916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","319.74","319.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia3Mm Nonlok","40005917","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.56","259.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia3Mm Nonlok","40005918","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","267.12","267.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Polyaxial Lok Scr 3.0 X 14Mm","40005919","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Bne Fix Leg L18X14Mm","40005920","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2441.1","2441.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pat Ant Cor St Ss","40005921","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3156.84","3156.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm Dia9Mm Nk 125Dg","40005922","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2631.15","2631.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 105Mm Sz 5 Std Offset","40005923","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3373.25","3373.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 51Mm 3 Lev","40005924","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4804.98","4804.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Va Sd 4.0Mmx14Mm","40005925","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1026.45","1026.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Va Sd 4.0Mmx16Mm","40005926","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1061.08","1061.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Fx Ang Sd 4.0Mmx14Mm","40005927","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1044.27","1044.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X44Mm Tib Cort","40005928","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","124.11","124.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plsh-2506/A Snap","40005929","CDM","270","RC","C1894","HCPCS","","","facility","both","","","","557.55","557.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Spnl Ant Crv 42Mm Std 3Lev","40005930","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1343","1343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X44Mm Xl25 Recess","40005931","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Fib Pstltrl R 6H 116Mm","40005932","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.37","898.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Reten For Scrdrvr Xl40","40005933","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","843.02","843.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L235Mm Dia9Mm Nk 125Dg","40005934","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2618.25","2618.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X26Mm Lok","40005935","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.4 Temp Fin Pin","40005936","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","252.87","252.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Feed 20Cc 24Fr Blln","40005937","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","186.02","186.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Feed L10Cm Dia16Fr Blln","40005938","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3318","3318","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Feed L10Cm Dia24Fr Blln","40005939","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","3318","3318","","","","","","","","","","","","","Gross Charge Type: Standard"
"Can 8Mm Std Len Obt W/Bldelss","40005940","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1360.38","1360.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 54Mm 3 Lev","40005941","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4993.41","4993.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Si Jt Fus L65Mm Dia7Mm","40005942","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4860.1","4860.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia10Mm R Fem","40005943","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3113.45","3113.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fem Prox R Sm 10H St","40005944","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5220.58","5220.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X16Mm Va T25 Strdrv","40005945","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","387.07","387.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth 10Deg L Bend Lok","40005946","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1741.79","1741.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X28Mm St Xl25 Rcss","40005947","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.15","530.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bs Hps Greenlightsf Ltd10-2090","40005948","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2324.18","2324.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiber Xps 2023","40005949","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2347.57","2347.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrsnk Sur Drl For 2/2.4Mm Sc","40005950","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","203.66","203.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.5X180Mm Str Ti","40005951","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L102Mm Dia25X14Mm","40005952","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","13297.23","13297.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Sterile Black Ultra Lp","40005953","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","660.58","660.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Dst R 4 H Lng","40005954","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2421.19","2421.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Human Tissue Talus Right","40005955","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4026.94","4026.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X90Mm St Recon","40005956","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","318.32","318.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Coag 6.9Fr L2.2M Cnvnent","40005957","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","465.81","465.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bone Fib Lat Dst R 4H 86Mm","40005958","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1087.8","1087.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bone Fib Lat Dst L 5H 99Mm","40005959","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1354.04","1354.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Clave Shft L Cs1 St","40005960","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1822.72","1822.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L80Mm","40005961","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Drg Elut Onyx 2.5Mmx26Mm","40005962","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Tlif Pt Specif Plan L4/L5","40005963","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","34060","34060","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 109Mm Sz 7 Std Offset","40005964","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3340.5","3340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pat Ant Cor Sm St","40005965","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2978.15","2978.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L285Mm Dia7Mm L Hum Bl","40005966","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2140.51","2140.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2.25Mm X 18Mm","40005967","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 114Mm Sz 4 Hi Offset","40005968","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2701.8","2701.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X88Mm Xl25 Recess","40005969","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.78","412.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L300Mm Dia13Mm Cann","40005970","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","806.09","806.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 133Mm Sz 7 Hi Offset","40005971","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2863.91","2863.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 26Mm 2 Lev","40005972","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4710.76","4710.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L100Mm Diamter 12Mm","40005973","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","17290.69","17290.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 4X40Mm Post Lrd","40005974","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","401.77","401.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L22Mm Dia3Mm","40005975","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Saph Vein L20-80Cm Dia3-6Mm","40005976","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","12942.8","12942.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia12Mm Dst Bnd","40005977","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2456.41","2456.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X60Mm Stardrv","40005978","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X75Mm Stardrv","40005979","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L220Mm D2.8Mm Thrd","40005980","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","359","359","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X90Mm Stardrv","40005981","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X13Mm","40005982","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Femoral 96Mm Sz 1 Std","40005983","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3950","3950","","","","","","","","","","","","","Gross Charge Type: Standard"
"Healix Adv Peek Anchr","40005984","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1341.42","1341.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implnt Brst 700Ml 13.3Cm 6.5Cm","40005985","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 12Mm 1 Level","40005986","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4767.29","4767.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Fx Ang 4.0Mmx16Mm","40005987","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1062.37","1062.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Picc 3Fr L20Cm Sl Midln","40005988","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","317.1","317.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L118Mm 6 H St L Prox","40005989","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2091.41","2091.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Szr Brst Od14.2Cm 425Ml P4.1Cm","40005990","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implnt Brst 425-475Cc P4.1-4.9","40005991","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","908.5","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 5Cc Allgrft Canc","40005992","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3029.16","3029.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X28Mm Cort Hex","40005993","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X65Mm T25 Stardrv","40005994","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","273.74","273.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X62Mm Cort Hex","40005995","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-9 16Mm R Fix Bear Ps Vivacit","40005996","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Cort T8","40005997","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 28Mm 2 Level","40005998","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4804.98","4804.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia22.2Mm -2Mm Nk","40005999","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","906.26","906.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm R Fem","40006000","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2937.22","2937.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Glen Fix Por Plsm Spr Mod","40006001","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","777.88","777.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tamp Bone Sz 2 Blln L10Mm Infl","40006002","CDM","278","RC","C1726","HCPCS","","","facility","both","","","","1488.99","1488.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X36Mm Crucfrm","40006003","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X44Mm Hex Drv","40006004","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","405.3","405.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X95Mm Cort Hex","40006005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.79","48.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 155Mm Sz 18 12/14 Nk","40006006","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 155Mm Sz 16 12/14 Nk","40006007","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 155Mm Sz 15 12/14 Nk","40006008","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 155Mm Sz 13 12/14 Nk","40006009","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 155Mm Sz 12 12/14 Nk","40006010","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1440.96","1440.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M Thk0.7Mm 3X4 H L","40006011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525.12","525.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone M Thk0.7Mm 3X4 H R","40006012","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.56","262.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia10Mm 130Deg","40006013","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3757","3757","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg L95Mm Dia10.5Mm","40006014","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","592.2","592.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R Dst Fib 8 H Lok Ss","40006015","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1382.5","1382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 32Mm 2 Lev","40006016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4899.19","4899.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Va St 4.3Mmx14Mm","40006017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Va St 4.3Mmx16Mm","40006018","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Spnl Fix Ang St 4.0Mmx14Mm","40006019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lig Polymr L Vesolock","40006020","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1404.45","1404.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bio Tiss W7Xl10Cm","40006021","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","1256.1","1256.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.9Mm Bc Achilles Pars/Amss Cc","40006022","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3602.5","3602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 101Mm Sz 3 Std Offset","40006023","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maryland Xp Inln Seal/Div 23Cm","40006024","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","790.4","790.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maryland Xp Ltch Seal/Div 23Cm","40006025","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","790.4","790.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Healix Adv Peek Anchr Dynatape","40006026","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1341.42","1341.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 6-9 Tib Ef","40006027","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2055.6","2055.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Bplr Electrd L5.74Mm","40006028","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1203.96","1203.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Lap Sm L18.8Cm Opn Jaw","40006029","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","849.66","849.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Tib C-D Fem 3-5 16Mm","40006030","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L150Mm Dia4Mm","40006031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.75","222.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L125Mm Dia4Mm","40006032","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.75","222.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L100Mm Dia4X3Mm","40006033","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.75","222.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handle Drvr Turning Noncann","40006034","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","808.5","808.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rack Strl W160Xh81.7Xl234Mm","40006035","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maryland Xp Inln Seal/Div 37Cm","40006036","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","833.2","833.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maryland Xp Ltch Seal/Div 37Cm","40006037","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","816.86","816.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maryland Xp Inln Seal/Div 44Cm","40006038","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","908.5","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Div Endoscp 5Mm-44Cm","40006039","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","908.5","908.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Surg W12Xl14In Uncoated","40006040","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2716.42","2716.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athrctmy D1.5Mm Preconn Exchg","40006041","CDM","272","RC","C1724","HCPCS","","","facility","both","","","","3013","3013","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7Fr L8In Polyur Cv 3L","40006042","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","230.62","230.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Optimizer Smart Mini Ipg","40006043","CDM","278","RC","C1824","HCPCS","","","facility","both","","","","34060","34060","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defibrillator Card Df4 Conn","40006044","CDM","278","RC","C1722","HCPCS","","","facility","both","","","","15752.75","15752.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Pace Transcatheter Micra","40006045","CDM","275","RC","C1786","HCPCS","","","facility","both","","","","20632.5","20632.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemkr Card 27Gm 6.5X53X52Mm","40006046","CDM","275","RC","C2621","HCPCS","","","facility","both","","","","7641.23","7641.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L138Cm Blln L12Mm Dia3Mm","40006047","CDM","278","RC","C1761","HCPCS","","","facility","both","","","","6157","6157","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Clsr 6Fr 0.035In Gwire","40006048","CDM","278","RC","C1760","HCPCS","","","facility","both","","","","524.05","524.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia11Mm Dst Bnd","40006049","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2962.69","2962.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Port Infus 8Fr Polyur Sl Attch","40006050","CDM","278","RC","C1788","HCPCS","","","facility","both","","","","808.5","808.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 140Mm 12Mm Conq Fx","40006051","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","190.26","190.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olcrnn Prox L 2H St","40006052","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1477.24","1477.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 103Mm Sz 4 Hi Offset","40006053","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3359.21","3359.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X36Mm Pat Lag Cann","40006054","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.29","367.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handpiece Ablat For Endomet Sy","40006055","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40006056","CDM","278","RC","C1760","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss 16.9Sqcm Amnio","40006057","CDM","278","RC","Q4186","HCPCS","","","facility","both","","","","3471.5","3471.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acss W14Xh6Xl12Mm","40006058","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3127.22","3127.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L45Mm Ant Cerv","40006059","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub Wdg 20X20X6.5Mm","40006060","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2603.84","2603.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Mtp L 0Deg Valgus","40006061","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3152.1","3152.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X20Mm Compr Va Ft","40006062","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X22Mm Compr Va Ft","40006063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X24Mm Compr Va Ft","40006064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X22Mm Mt Cort Ti Lp","40006065","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Temp Fix Bb-Tak Mtp","40006066","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","136.76","136.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth Dia0.045In","40006067","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","60.17","60.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X20Mm Cort Hex Ft","40006068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","72.98","72.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X18Mm Polyax","40006069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 30Mm 2 Level","40006070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4852.08","4852.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X20Mm Stardrv","40006071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X22Mm Stardrv","40006072","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X24Mm Stardrv","40006073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X32Mm Stardrv","40006074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X38Mm Stardrv","40006075","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X40Mm Stardrv","40006076","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Stardrv","40006077","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"105Mm Ss Va-Lcp For 2.7Mm Scrw","40006078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1424.51","1424.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +8.5 Offset","40006079","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","900.6","900.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne 4.5X70Mm Cort Hex Drv","40006080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","91.13","91.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 6 H Crv 90.5Mm","40006081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","972.17","972.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 3 H Str 42.5Mm","40006082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","801.3","801.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 6 H Str 90.5Mm","40006083","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882.59","882.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 8H Str 122.5Mm","40006084","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","882.59","882.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"46.5Mm Ss Mps For 3.5/4.5Mm Sc","40006085","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","927.38","927.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth 3.2Mm X 300Mm","40006086","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","104.94","104.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotd L40Mm Dia7Mm","40006087","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3732.19","3732.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X52Mm Cort Hex","40006088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 2H St Spr Ss Lp Pelv","40006089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","489.3","489.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X28Mm Cort Hex Hd","40006090","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","71.01","71.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pelv 4 H Str 58.5Mm","40006091","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","888.3","888.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteoaugr Bne Grft Harvstr 8Mm","40006092","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","919.48","919.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2Mm Cann","40006093","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal  6Mmx90Mm Post Crv","40006094","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 11Mm 1 Level","40006095","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4899.19","4899.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hi Prss 5.0Mmx30Mm X145Cm","40006096","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disk Artfcl W15Xh5Xl17Mm Cerv","40006097","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14148","14148","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ti H1.5Mm Mandbl 3X3","40006098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1177.1","1177.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X8Mm Cort Ft Lok","40006099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","197.4","197.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nmp Fibers Cc","40006100","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","5461.41","5461.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 3.5X70Mm Post","40006101","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5H 38Mm Ss Mod Mini","40006102","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","461.12","461.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X80Mm Pelv Cort","40006103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","62.3","62.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Lap L37Cm Shft Dia5Mm","40006104","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2977.45","2977.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Lap L37Cm Shft Dia10Mm","40006105","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2698.84","2698.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L190Cm Dia0.014In","40006106","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L100Cm Gwire 0.035In","40006107","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","394.8","394.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L60Mm Dia10Mm","40006108","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L75Cm Blln L40Mm Dia12Mm","40006109","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L26Cm Hydr+","40006110","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","342.42","342.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 5.5Mm X 80Mm Blln 150Cm","40006111","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Catheter 6.00Mm X 15Mm","40006112","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5.8Fr L180Cm Blln","40006113","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","472.52","472.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Litho 1.9Fr X 375Cm","40006114","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","472.52","472.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 2Mm Cann Sc","40006115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409.5","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 2.5Mm Cann","40006116","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409.5","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns For 3Mm Cann Sc","40006117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409.5","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X46Mm Xl25 Recess","40006118","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Ant Cerv 39Mm Std","40006119","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1343","1343","","","","","","","","","","","","","Gross Charge Type: Standard"
"Overdrill Sur For 3.5Mm Scr","40006120","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","502.74","502.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bc Achilles Spdbrg W/ Kl Dx Cc","40006121","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3849.34","3849.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheth Guid 6Fr L80Cm Wrk L75Cm","40006122","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","704.97","704.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L56Mm Dia4Mm Cort Ss","40006123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","57.86","57.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Surgical Dia6.5Mm Asym","40006124","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3118.75","3118.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 2.5Mm Qc L 400 Mm","40006125","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1012.83","1012.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Fix Wire 2.5Mm Len 150Mm","40006126","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","76.66","76.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Temp Fix Wire 2.5Mm Len 220Mm","40006127","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","76.66","76.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pat Ant 6 H St Ss","40006128","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3276.05","3276.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidepin Drl Tip L311Mm D2.4Mm","40006129","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","84.16","84.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 0.014Inx300Cm","40006130","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Vasc 0.018Inx300Cm","40006131","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Suture L17.9 D3.9 Peek","40006132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Robtc Dia14Mm Ln L45Mm","40006133","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","857.49","857.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40006134","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ang Sd 4.0Mmx12Mm","40006135","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1048.09","1048.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X120Mm","40006136","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 10H 3Rd Tblr Lok Ss","40006137","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Compr Ss","40006138","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm Compr Ss","40006139","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Compr Ss","40006140","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","619.5","619.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Cann Lng","40006141","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Crd 21Gm 6.5X40X48Mm","40006142","CDM","275","RC","C1786","HCPCS","","","facility","both","","","","6192.19","6192.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surf Artc Tib C-D Fem 3-5 13Mm","40006143","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1790.22","1790.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L50Mm Od5Mm Pedcl","40006144","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 5.4X180Mm Str Perc","40006145","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vlv 8Fr L100Cm L4Cm D20Mm","40006146","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon L 8 H St","40006147","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X20Mm Cort Ft Lok","40006148","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia4Mm Co Ally","40006149","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Defib L60Cm Plexa Promri","40006151","CDM","275","RC","C1777","HCPCS","","","facility","both","","","","360.25","360.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hi Prss 4.5Mmx30Mmx145Cm","40006152","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coil Emb Pri L50Cm Ves 5-6Mm L","40006154","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L40Cm Cereb","40006155","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","875.7","875.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm Blln L150Mm","40006156","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hi Prss 2.75Mmx30Mmx145Cm","40006157","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Compr 10Ml Bnd L24Cm L","40006158","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","710.1","710.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Vasc Compr Mod 4160 Rdr","40006159","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","856.8","856.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm Blln L300Mm","40006160","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm Blde L10Mm","40006161","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath  Hi Prss 5.0Mmx20Mmx145Cm","40006162","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm Blln L10Cm","40006163","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Vasc L100Mm Dia7Mm Cath","40006164","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plte Bne W10.1Xl112Mm Thk3.5Mm","40006165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirex 8Fr Catheter 110Cm","40006166","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","4323","4323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Endoscp For Sft Tiss","40006167","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1414.1","1414.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal L60Mm Post Ti","40006168","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","955.68","955.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od50Mm Id28Mm Fem","40006169","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1208.7","1208.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es 26Fr Wre 0.35In","40006170","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","197.4","197.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Knife","40006171","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","151.2","151.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Loop 26Fr 12Deg Mplr","40006172","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","243.6","243.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Mplr Dia28Fr 12Deg","40006173","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","197.4","197.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Roller Bar              704100","40006174","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","218.4","218.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 1.6X150Mm Sgl End Smth","40006175","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","23.15","23.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Canc Hex Drv","40006176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.52","403.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Canc Hex Drv","40006177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.52","403.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3 H Slim Y Plt Ti","40006178","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2218.08","2218.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 2 H Ank Ft Ti Broad","40006179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2604.63","2604.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm T8 Drv Ft","40006180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.52","403.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm T8 Drv Ft","40006181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.94","235.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm T8 Drv Ft","40006182","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.94","235.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm T8 Drv Ft","40006183","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.94","235.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm T8 Drv Ft","40006184","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.94","235.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X24Mm T8 Drv Ft","40006185","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.94","235.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm T10 Drv Ft","40006186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm T10 Drv Ft","40006187","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X18Mm Dst Tib","40006188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","72.98","72.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm T10 Drv","40006189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm T10 Drv","40006190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2Mm Scaled","40006191","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","260.19","260.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X26Mm Polyax","40006192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","430.92","430.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X18Mm Fix Ang","40006193","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrpc Spnl 24-32Mm 13Mm Thrlm","40006194","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","13618.76","13618.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Polyax 7.5Mmx55Mm","40006195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3199.01","3199.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Polyax 6.5Mmx55Mm","40006196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.28","1842.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Prox L 11 H St","40006197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4832.33","4832.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fem Dst L 4 H St","40006198","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2597.52","2597.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ss Conn For Lok","40006199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","387.81","387.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L170Mm Dia2.8Mm Calib","40006200","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5X45Mm","40006201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2133","2133","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L60Mm Dia5.5Mm Ti","40006202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 34Mm 2 Lev","40006203","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4852.08","4852.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ang St 4.3Mmx14Mm","40006204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1042.56","1042.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Powder Hemstat 3Gm Purify Plnt","40006205","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1732.9","1732.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia2.7Mm Mtph","40006206","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","557.3","557.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia2.7Mm Mtph","40006207","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","557.3","557.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L14Mm Dia2.7Mm Mtph","40006208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","557.3","557.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admrl Av Dcb 7Frx8Mmx60Mmx80Cm","40006209","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2204.1","2204.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 6Fr 2.1Fr 24Cm 2","40006210","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","941.02","941.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L95Mm Dia3.5Mm Ank","40006211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","279.3","279.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Protct For Fns Insrt","40006212","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph Superficial Fem","40006213","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"L130Cm Blln 6X60Mm In.Pact 018","40006214","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"L130Cm Blln 6X100Mm In.Pct 018","40006215","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Diag L150Cm Id0.0175In","40006216","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Had Hem-Flo 14.5Fr X 28Cm","40006217","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal W14Xh5Xl12Mm 7Deg","40006218","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X95Mm St Va T25","40006219","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Crv Ti Lrd 3.5Mmx35Mm","40006220","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedcl 3.5Mmx32Mm","40006221","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedcl 3.5Mmx34Mm","40006222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L24Cm Percflx","40006223","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","292.36","292.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 34Mm 2 Lev","40006224","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1690.05","1690.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"2-Lev Carlsmed-Pt Specif Tlif","40006225","CDM","278","RC","C1831","HCPCS","","","facility","both","","","","41920","41920","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical S-A Screw 3.75Mmx14Mm","40006226","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura Ad W2Xl2In","40006227","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W18Xh6Mm D16Mm","40006228","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W18Xh7Mm D16Mm","40006229","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Ant Cerv 52Mm 3Lev","40006230","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cerv S-A Screw 3.75Mm X 16Mm","40006231","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cortium Screw 3.5Mm Len 16Mm","40006232","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cortium Screw 3.5Mm Len 14Mm","40006233","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cortium Screw 3.5Mm Len 26Mm","40006234","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cortium Thor Screw 4.5Mm Len","40006235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cortium Thor Screw 4.5Mm Len","40006236","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Locking Screw","40006237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 4Mmx120Mm Post","40006238","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ucerv Acs 3D Ti 17Mmx14Mmx6Mm","40006239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ucerv Acs 3D Ti 17Mmx14Mmx7Mm","40006240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L114Mm 5 H Std Prox","40006241","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trachbrnch L38Mm Dia10Mm","40006242","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Retrv 20Mm 2 Shth Snr Bard","40006243","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blln Stone Retrv L200Cm Dia12","40006244","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Lsr 14Fr L50Cm Ld 7.5Fr","40006245","CDM","272","RC","C2629","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth Lsr Gldlght 25-80Hz L50Cm","40006246","CDM","272","RC","C2629","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth Dil Mech Shrtie 11Fr Evol","40006247","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6-7Fr L200Cm Blln D9-12Mm","40006248","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl 2X6 H 44Mm Ss","40006249","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 12 H Str 71Mm Ss Va","40006250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pack Endovenous Cath 7Fr L60Cm","40006251","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 10Cc Ca Phspte","40006252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 7.5Fr L240Cm Blln","40006253","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Bio Tiss W4Xl4Cm Prcrd","40006254","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L33Cm Od2.8Mm Id1.5Mm Flo","40006256","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L5Cm Dia6Mm Cath","40006257","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L39Mm Dia10-13Mm","40006258","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur W20Xl25Cm Sepra Tech","40006259","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Evar Stnt L59Mm Dia8-11Mm","40006260","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Rad 5Cm Del Ndl","40006261","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Rad 10Cm Del Ndl","40006262","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Brst Loc 7.5Cm Del Ndl","40006263","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L45Cm Dia4-7Mm","40006264","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5.8Fr L75Cm Blln L4Cm","40006265","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Seal Tract Slf Exp Hydrgel","40006266","CDM","278","RC","C2613","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Sut Str For Menisci Rep","40006267","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olcrn R 4H St 116Mm","40006268","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox L 4H St Sm","40006269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Crd 23Gm 6.5X44X48Mm","40006270","CDM","275","RC","C1785","HCPCS","","","facility","both","","","","360.25","360.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia3Mm Orsiro","40006271","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Tiss Rem L32Cm Dia3Mm","40006272","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum Ext Med Dst R 1","40006273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L32Mm 7 H Cndyl Ss","40006274","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum X-Artc Dst L 8H","40006275","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olcrn L 4H St 116Mm","40006276","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Va Ft Lok","40006277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Va Ft Lok","40006278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Va Ft Lok","40006279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X70Mm Compr Canc","40006280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Dia6In Polypr Polygly","40006281","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W4Xl6In Mfil Resrb","40006282","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Mic Byps Ad H360Um D230Um","40006283","CDM","278","RC","C1783","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Icd Acticor 7 Hf-F-Qp Mr","40006284","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hern M Cir W/Strp Vntrlx","40006285","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 14Fr L29Cm Ndl 18Ga L5X9C","40006286","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","571.2","571.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern 8X10In W/Opn Pos Sys","40006287","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16Mm Dia5Mm Nst","40006288","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Tiss Rem L12.6In Dia4Mm","40006289","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibulink Syndesmosis Rep","40006290","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem L127Mm Sz6 Std Offset","40006291","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W12Xl160Mm Thk3.7Mm","40006292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L100Mm Dia8Mm Cath","40006293","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L138Cm Blln L12Mm D2.5Mm","40006294","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Vasc Clsr Sut Mediated","40006295","CDM","278","RC","C1760","HCPCS","","","facility","both","","","","364.18","364.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Map 48 Pole 2-2Mm","40006296","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Us 10Fr L90Cm Gray","40006297","CDM","272","RC","C1759","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dia0.035In 24Mm Pgtl Rf Wire","40006298","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Us 10Frx90Cm Soundstar","40006299","CDM","272","RC","C1759","HCPCS","","","facility","both","","","","429.76","429.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Fj 1-6-2Mm 115Cm","40006300","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","356.32","356.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appl Clp Shft 29Cm Pstl Grp 10","40006301","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","886.16","886.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare Es L230Cm Loop Dia15Mm","40006302","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","287.28","287.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Cage 9 Sx 10X5X20 Degree","40006303","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psx Cage 7 Sx 10X25X20 Degree","40006304","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L82Mm Dia5Mm Ti Ally","40006305","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","331.91","331.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L67Mm Dia5Mm Ti Ally","40006306","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","331.91","331.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L62Mm Dia5Mm Ti Ally","40006307","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","331.91","331.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L50Mm Dia5Mm Lok Lp","40006308","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X52Mm Xl25 Recess","40006309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L390Mm Dia8Mm Univ Dk","40006310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1521.65","1521.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 3.5Mm Qc Len 380 Mm","40006311","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1012.83","1012.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Dst Attch L4Mm Dia11.35Mm","40006312","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","178.84","178.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L180Cm Dia0.018In","40006313","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","390.6","390.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Sft-Vu Bern 4Fx40Cmx3Cm","40006314","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","447.3","447.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L190Cm Dia0.014In","40006315","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","987.5","987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Foam W3Xl3In Hydrphlc Sq","40006316","CDM","272","RC","A6212","HCPCS","","","facility","both","","","","46.87","46.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L60Mm Dia2Mm","40006317","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L150Mm Dia8Mm Cath","40006318","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5534.75","5534.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L80Mm Dia6.5Mm","40006319","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2175.66","2175.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ty Bx 11Ga L152Mm Ss Bone Mar","40006320","CDM","272","RC","C1830","HCPCS","","","facility","both","","","","1382.5","1382.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ty Bx L15Cm 13Ga L19Cm 11Ga","40006321","CDM","272","RC","C1830","HCPCS","","","facility","both","","","","3661.45","3661.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm Dia6Mm Cath","40006322","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1047.54","1047.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L80Mm Dia6Mm Cath","40006323","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1047.54","1047.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm Blde L6Mm Bll","40006324","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1501","1501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia3Mm Plat","40006325","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.0Mm X 28Mm  Synergy Xd","40006326","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Graft 11Mm X 5Cm X 120Cm","40006327","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4380.64","4380.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expander Brst Tiss 850Cc Sil","40006328","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","2724.8","2724.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Dcplr F Crv 7Fr L115Cm","40006329","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","1839.12","1839.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ablat F J Crv 7Fr L115Cm","40006330","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","3176.75","3176.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Mapping 3-3-3-3-3 Octaplr","40006331","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","3343.12","3343.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L135Cm L60Mm Dia6Mm","40006332","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4519.5","4519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng20012Ux Onyx","40006333","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Promri Intica Neo 7 Vr-T","40006334","CDM","275","RC","C1722","HCPCS","","","facility","both","","","","15065","15065","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L13Mm","40006335","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L13Mm","40006336","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L18Mm","40006337","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L15Mm","40006338","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L26Mm","40006339","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L30Mm","40006340","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Orsiro Mssn D2.25Mm L13Mm","40006341","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L22Mm","40006342","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D2.5Mm L26Mm","40006343","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L22Mm","40006344","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L40Mm","40006345","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X22Mm Canc Hex Hd","40006346","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L18Mm","40006347","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L35Mm","40006348","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L18Mm","40006349","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L22Mm","40006350","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L26Mm","40006351","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D3.5Mm L30Mm","40006352","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Orsiro Mission D4Mm L15Mm","40006353","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn D2.5Mm L15Mm","40006354","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L15Mm","40006355","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia3Mm L26Mm","40006356","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L35Mm","40006357","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Orsiro Mssn Dia4Mm L30Mm","40006358","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.5X80Mm Compr Hdlss","40006359","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1356.85","1356.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne 5.5X110Mm Compr Hdlss","40006360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1356.85","1356.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc R Lg Std","40006361","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3156.29","3156.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc R Lg Ext","40006362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3282.65","3282.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc L Lg Std","40006363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3156.29","3156.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Acet Intrplvc L Lg Ext","40006364","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3282.65","3282.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cmf 4H X Thck 0.5Mm","40006365","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1042.29","1042.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L220Mm Dia3.2Mm St","40006366","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","171.21","171.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eustachian Tb Blln 6 X 20 Mm","40006367","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","3340.5","3340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X36Mm Compr Hdlss","40006368","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1020.87","1020.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X55Mm Compr Hdlss","40006369","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1020.87","1020.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Dst Lat 3H 77Mm","40006370","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","745.5","745.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Fib Cort","40006371","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","216.47","216.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm Fib Cort","40006372","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X28Mm Fib Cort","40006373","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","216.47","216.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Fib Cort","40006374","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uret Stnt 6Fr L28Cm Perflex","40006375","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","335.71","335.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Cv 2 Lumn W/ Arwgrd + Blu","40006376","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","272","272","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thrmdil 7.5Fr L110Cm Cont","40006377","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","484.51","484.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Picc Ad Ped 5Fr L30Cm Pvc","40006378","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","184.8","184.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centralizer Stem Dia10Mm Univ","40006379","CDM","278","RC","C1734","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm T10 Drv Ft","40006380","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm T10 Drv Ft","40006381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm T10 Drv Ft","40006382","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm T10 Drv Ft","40006383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L122Mm Dia3.5Mm Add","40006384","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","260.19","260.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm T10 Drv Ft","40006385","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia3.5Mm Evero","40006386","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz E-F Fem Sz","40006387","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Laminplsty L6Mm Thrt 6Mm","40006388","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1039.5","1039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Laminplsty L8Mm Thrt 6Mm","40006389","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1039.5","1039.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Laminplsty L5Mm Dia2.6Mm","40006390","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","144.65","144.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Laminoplasty L7Mm Dia3Mm","40006391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","144.65","144.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz C-D Fem Sz","40006392","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm +0Mm Offset","40006393","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Ti Mis Lord Vi2 5.5Mm","40006394","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","691.93","691.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Vcrl Sz 1 L18In Absrb Vlt","40006395","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","46.29","46.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphere Rad Loc Mark Navi Ball","40006396","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1908.64","1908.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Identiti Alif Sa Spcr 6X38X28M","40006397","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7860","7860","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Va Sd 4.0Mmx12Mm","40006398","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Motoclip/Himax Impant Sys Is A","40006399","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1965","1965","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia3Mm Nonlck","40006400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28Mm Dia3Mm Nonlck","40006401","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anti-Drift Bolt Ft 3.5X34","40006402","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","948","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Rmr Bolt Anti Drift Pk Out","40006403","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fix Dia2Mm Sht Dynabunion","40006404","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.27","451.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fix Dia2Mm Lng Dynabunion","40006405","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","451.27","451.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Motoband Cp Impl Sys Dynabunio","40006406","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2607","2607","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.6 Fibertak Kntlss","40006407","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","837.4","837.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conduit Aort Vlv 29Mm Resilia","40006408","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","19650","19650","","","","","","","","","","","","","Gross Charge Type: Standard"
"Assurance Clip 13Mm","40006409","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L25Mm Dia10Mm Ant","40006410","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.5","556.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Sur St Irrig Mako Integr","40006411","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","241.92","241.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Sur 6Mm Ball","40006412","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","195.67","195.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Anchr Biocomposite Swvlck","40006413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2749.2","2749.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Bone Fix 3.2Mm X 140Mm","40006414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","272.16","272.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix 3.2X110Mm Bone","40006415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","272.16","272.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Bone Fix 4X170Mm","40006416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","272.16","272.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trk Hip Proc Vizadisc","40006417","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","459.9","459.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Dir Meas Fr 3.2Mm Gwire","40006418","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","830.59","830.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Hld Dia2Mm For Ft Ank","40006419","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","529.54","529.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Hld Dia2.5Mm For Ft Ank","40006420","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","529.49","529.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X66Mm Xl25 Recess","40006421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X68Mm Xl25 Recess","40006422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Im Nail Assembly","40006423","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","909.64","909.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Compr Distr For Ft Ank","40006424","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2758.33","2758.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Skin 35 Wide Stpl Disp","40006425","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","42.08","42.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L90Mm Std 3 H Prox","40006426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2161.44","2161.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L150Mm D5Mm Thrd","40006427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.85","222.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X34Mm Hindfoot","40006428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X40Mm Hindfoot Cort","40006429","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Pin L100Mm Dia2Mm Absrb","40006430","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 7 H Str 99Mm Ss Sm","40006431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1010.23","1010.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L200Mm D5Mm Thrd","40006432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","253.66","253.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mini 3.6X22Mm Calcnl","40006433","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1444.12","1444.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im Valor Sm L150Mm Od10Mm","40006434","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5167.69","5167.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Surg L80Mm Dia10.5Mm","40006435","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.37","991.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Minilok Quik Anchr","40006436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1153.4","1153.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia9Mm 130Deg","40006437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2748.75","2748.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Fibertag Tghtrp","40006438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X36Mm Fib Cort Ft","40006439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X18Mm Fib Cort Ft","40006440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5 H 1/3 Tblr W/Cllr","40006441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2421.19","2421.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Fib Cort","40006442","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L35Mm Thk1.9Mm Ant","40006443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2137.74","2137.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blu Wht Blk Fbr Tape Loop 3Mm","40006444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm 130Deg","40006445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3144.18","3144.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X10Mm Polyax","40006446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","623.7","623.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.4Mm","40006447","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","921.9","921.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Defib Ldwire L42In","40006448","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","70.98","70.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microcath Guid 130Cm Od2.5Fr X","40006449","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 8Fr L110Cm Gwire 0.018In","40006450","CDM","272","RC","C1724","HCPCS","","","facility","both","","","","4585","4585","","","","","","","","","","","","","Gross Charge Type: Standard"
"Handle Sl Hld Tight Dev","40006451","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","529.54","529.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Hld Dia3Mm","40006452","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","529.54","529.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Reamer 13Mm","40006453","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","858.71","858.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cylinder Surg Fem Nk Sys","40006454","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","809.58","809.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L170Mm Dia9Mm 130Deg","40006455","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2243.39","2243.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X38Mm Hindfoot Cort","40006456","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L23Mm Dia7Mm","40006457","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","724.5","724.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L15Mm Dia6.25Mm","40006458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L240Mm Dia7Mm R Tan","40006459","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2140.51","2140.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X42Mm Fib Cort","40006460","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","388.91","388.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40006461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L119Mm 6H L Med Prox","40006462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X22Mm Va Dst Rad","40006463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","390.79","390.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fix W8Xl12Mm Ti Attch","40006464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X32Mm Hindfoot Cort","40006465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","526.8","526.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Shft R Cs2 St","40006466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1972.79","1972.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X44Mm Va Ft Lok","40006467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Sup Midshaft Clav L","40006468","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1886.52","1886.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L75Mm Od10.35Mm Ns","40006469","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","941.05","941.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 H 58Mm Ss Lp Mod","40006470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","780.47","780.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Fib Cort","40006471","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","496.1","496.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm Univ","40006472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1702.59","1702.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia11Mm Univ","40006473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1702.59","1702.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Schanz 4.0/3.0 X 80Mm Tita","40006474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon R 2 H St","40006475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1652.54","1652.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X44Mm Hindfoot Cort","40006476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X3Mm Cmf Ft Slf","40006477","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","132.3","132.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X90Mm Va T25 Star","40006478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bone L75Mm Dia10Mm G Ti","40006479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Va T8","40006480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","321.42","321.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L375Mm Dia10Mm Univ","40006481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1521.65","1521.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Olecranon Prox R 2H","40006482","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1477.24","1477.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 H 1/3 Tblr W/Cllr","40006483","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","518.92","518.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne Mic 2.5X2.8X9Mm Compr","40006484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1444.12","1444.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X34Mm Fib Cort Ft","40006485","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","496.1","496.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 H Str 52Mm Ss Lp","40006486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","615.91","615.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 6X5 H Std 22X75Mm Ss","40006487","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X5 H Std 22X75Mm Ss","40006488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1388.58","1388.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X16Mm Cort Ft St","40006489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","323.84","323.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mini 3.5X3.6X28Mm","40006490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","907.2","907.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.1X32Mm Calcnl","40006491","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","907.2","907.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 6 H 85Mm Ti Lcp","40006492","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","599.61","599.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Canc Hex Hd","40006493","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L225Mm Dia6Mm","40006494","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","489.83","489.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Pubic Symphysis 6 H","40006495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1303.15","1303.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X28Mm Va Dst Rad","40006496","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","246.04","246.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 7X3 H Wide 25.5X55Mm Ss","40006497","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1290.56","1290.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 7X3 H Wide 25.5X55Mm Ss","40006498","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1290.56","1290.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 5 H 72Mm Ss Lcp","40006499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","596.95","596.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Extract Sys Ct-All Maxi 7","40006500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1264","1264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 6X2 H Std 22X45Mm Ss","40006501","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1240.96","1240.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 7X2 H Wide 25.5X47Mm Ss","40006502","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1240.96","1240.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 6X2 H Nar 19.5X42Mm Ss","40006503","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1240.96","1240.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X2 H Nar 19.5X42Mm Ss","40006504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1240.96","1240.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L20Mm Dia3.5Mm Cort","40006505","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","801.36","801.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia5Mm Ns","40006506","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","533.93","533.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5Mm Pk Kntlss Heali","40006507","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X25Mm Ft Ti Ally","40006508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filler Bone Void 3Cc Ca Phspte","40006509","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1183.03","1183.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X4Mm Crss Cort","40006510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","783.97","783.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X10Mm Cort Ft","40006511","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm Va Ft Lok","40006512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X24Mm Va Ft Lok","40006513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","255.82","255.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X26Mm Va Ft Lok","40006514","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W21.6Xl48.9Mm Sht","40006515","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1138.07","1138.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X36Mm Thrd Hd Lok","40006516","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.4X30Mm Va T8","40006517","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","246.04","246.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L54Mm 7 H Bilat Ss","40006518","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1095.97","1095.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X14Mm Condyle Va","40006519","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","482.94","482.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X16Mm Condyle Va","40006520","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","482.94","482.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X130Mm Canc Hex","40006521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X38Mm Fib Cort","40006522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Fib Cort","40006523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","466.87","466.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.4X75Mm St Fem Nk","40006524","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60Mm Condyle Va","40006525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X75Mm Fib Cort","40006526","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X34Mm Compr","40006527","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1020.87","1020.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Cort Ft","40006528","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X18Mm Cort Ft","40006529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","430.92","430.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X12Mm Cort Ft","40006530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat Dst R 7 H","40006531","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","972.43","972.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L76Mmxw9Mm Ank 5 H","40006532","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","971.23","971.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Lat Dst L 5 H St","40006533","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","945.72","945.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 10.35X110Mm Fen Cann","40006534","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","439.24","439.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 10.35X70Mm Fen Cann","40006535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","941.05","941.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat Dst R 9H","40006536","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","925.07","925.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L8Mm Dia1.3Mm Grn Ss","40006537","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.9","244.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X80Mm Va Tib Ft","40006538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.48","472.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X38Mm St Hum","40006539","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.03","403.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne M Thk0.5Mm 20 H","40006540","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","895.58","895.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X28Mm Cort Ft","40006541","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat Dst L 4 H","40006542","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","872.87","872.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L22Mm D1.8Mm Ss Bttrs","40006543","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","231.46","231.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X12Mm Mand Cort Ft","40006544","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","867.03","867.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X22Mm Cort Ft St","40006545","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L77Mm 3 H Ns R","40006546","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","859.54","859.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Bne 5X40Mm Va T25 Stardrv","40006547","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia2.7Mm Cort","40006548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","221.59","221.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Cort Ft","40006549","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Cort Ft","40006550","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.45","219.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X68Mm Canc Cann","40006551","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Compr Cann","40006552","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X44Mm Compr Cann","40006553","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","535.08","535.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl 2X6 H 36Mm Ss","40006554","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","794.82","794.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 8H 1/3 Tblr W/Cllr","40006555","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.88","504.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X85Mm Condyle Va Ft","40006556","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X65Mm Condyle Va Ft","40006557","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X36Mm Va Ft Lok","40006558","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.15","365.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia2.4Mm Ss St","40006559","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","202.78","202.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X7 H Y Plt 42Mm Ss","40006560","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1006.78","1006.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 3X7 H T Plt 40Mm Ss","40006561","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1006.78","1006.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L28Mm Dia8Mm Cann","40006562","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","493.5","493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X42Mm T25 Stardrv","40006563","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X46Mm T25 Stardrv","40006564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X120Mm Canc Hex","40006565","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X150Mm Canc Hex","40006566","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X135Mm Canc Hex","40006567","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X145Mm Canc Hex","40006568","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X75Mm Canc Hex","40006569","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X105Mm Canc Hex","40006570","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X125Mm Canc Hex","40006571","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X135Mm Canc Hex","40006572","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X125Mm Canc Hex","40006573","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 6.5Mm X 135Mm W/32Mm","40006574","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X145Mm Canc Hex","40006575","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X80Mm Condyle Va","40006576","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","468.45","468.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X11Mm Cort Ft Lok","40006577","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mini 3.5X3.6X18Mm","40006578","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","907.2","907.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mini 3.6X20Mm Calcnl","40006579","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","907.2","907.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X12Mm Cort Ft Lok","40006580","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X14Mm Cort Ft","40006581","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X16Mm Cort Ft","40006582","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm Hexalobe","40006583","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L6Mm Dia2Mm Hnd Ss","40006584","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.72","281.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X40Mm Ank Cort Ft","40006585","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","408.24","408.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X40Mm St Hum Thrd","40006586","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.03","403.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X36Mm St Hum Thrd","40006587","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.03","403.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X36Mm Compr Thrd","40006588","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 9 H Str 117Mm Ss Lp","40006589","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","798.4","798.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X20Mm Cort Hex Hd","40006590","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X20Mm Cort Ft St","40006591","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L6Mm Dia1.3Mm Hnd","40006592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.9","244.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L7Mm Dia1.3Mm Grn","40006593","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.9","244.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X48Mm Cort Ft Lok","40006594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X52Mm Cort Ft Lok","40006595","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X64Mm Canc Hex Drv","40006596","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X24Mm Fib Cort Ft","40006597","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X40Mm Condyle Va Ft","40006598","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X44Mm Condyle Va Ft","40006599","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X46Mm Condyle Va Ft","40006600","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Orbit Rim Mini 12 H","40006601","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","655.91","655.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Va Tib Ft","40006602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","528.14","528.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Va Tib Ft","40006603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Cort Ft","40006604","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X24Mm Cort Ft","40006605","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126","126","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L200Mm Dia5Mm","40006606","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X14Mm Va Hnd Thrd","40006607","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.72","281.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2X16Mm Va T6 Stardrv","40006608","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.72","281.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X80Mm 2 Cor Tib","40006609","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","272.64","272.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Compr Cann","40006610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","535.08","535.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Compr Cann","40006611","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X28Mm Compr Cann","40006612","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","515.97","515.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X24Mm Va Ank Ft","40006613","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L250Mm Dia5Mm","40006614","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L14Mm Dia1.3Mm Hnd","40006615","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.9","244.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60Mm T25 Stardrv","40006616","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X10Mm Condyle Va","40006617","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","482.94","482.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X85Mm Canc Hex","40006618","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X115Mm Canc Hex","40006619","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X80Mm Canc Hex","40006620","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X100Mm Canc Hex","40006621","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X105Mm Canc Hex","40006622","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X60Mm Fib Cort","40006623","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X55Mm Fib Cort","40006624","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.3X12Mm Cort T4","40006625","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Cort Ft","40006626","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X18Mm Cort Ft","40006627","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X44Mm St Hum Thrd","40006628","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.03","403.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L12Mm Dia5Mm St Lok","40006629","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","402.47","402.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L125Mm Dia4Mm","40006630","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","198.79","198.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fix Uhmwpe Attch Sys","40006631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","386.4","386.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L26Mm Dia5Mm Va T25","40006632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X30Mm Va T25","40006633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32Mm Va Lok St","40006634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","373.72","373.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X46Mm Thrd Hd Lok","40006635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X18Mm Mtphseal","40006636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L11Mm Dia1.3Mm Cort","40006637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Canc Cann","40006638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X36Mm Condyle Va Ft","40006639","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X30Mm Condyle Va Ft","40006640","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X34Mm Condyle Va Ft","40006641","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X75Mm Condyle Va Ft","40006642","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","344.9","344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L7Mm Dia2Mm Cort Ss","40006643","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8Mm Dia2Mm Cort Ss","40006644","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X18Mm Cort Ft Lok","40006645","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone W9Xl57Mm Thk1Mm 5 H","40006646","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.26","324.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X32Mm Cann Prtly","40006647","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X36Mm Cann Prtly","40006648","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X85Mm St Recon","40006649","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","308.2","308.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm Va Tib Ft","40006650","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305.51","305.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm Va Tib Ft","40006651","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305.51","305.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm Va Tib Ft","40006652","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305.51","305.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Hexalobe","40006653","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","285.6","285.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L9Mm Dia2Mm Hnd 316L","40006654","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.72","281.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X70Mm Fib Cort Ft","40006655","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X75Mm 2 Cor Tib","40006656","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L85Mm Dia5Mm Cort G","40006657","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","272.64","272.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix 5X200Mm Blnt","40006658","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","167.77","167.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.3X18Mm Cort Thrd","40006659","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone  2.3X22Mm Cort Thrd","40006660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.2","256.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X44Mm Va Ank Ft","40006661","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X50Mm Va Ank Ft","40006662","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","255.82","255.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X28Mm Hum Ft Lok","40006663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X30Mm Hum Ft Lok","40006664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Hum Ft Lok","40006665","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X52Mm T25 Stardrv","40006666","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm T25 Stardrv","40006667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X58Mm T25 Stardrv","40006668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X78Mm T25 Stardrv","40006669","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X80Mm T25 Stardrv","40006670","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","583.8","583.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X85Mm T25 Stardrv","40006671","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X90Mm T25 Stardrv","40006672","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X20Mm T25 Stardrv","40006673","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X22Mm T25 Stardrv","40006674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L18Mm Dia4Mm Blu Ti","40006675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X52Mm Fib Cort Ft","40006676","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X10Mm Mand Cort Ft","40006677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","230.48","230.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X35Mm Canc Hex","40006678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","79.58","79.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Mtphseal","40006679","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X38Mm Mtphseal El","40006680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X42Mm Mtphseal El","40006681","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L15Mm Dia1.3 Mm Cort","40006682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L16Mm Dia1.3Mm Cort","40006683","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L18Mm Dia1.3Mm Cort","40006684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L13Mm Dia1.3Mm Cort","40006685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.3X7Mm Cort T4","40006686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.3X8Mm Cort T4","40006687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.3X9Mm Cort T4","40006688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.27","116.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X20Mm Canc Hex Drv","40006689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X32Mm Tib Cort Ft","40006690","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.5X6Mm T4 Stardrv","40006691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.04","102.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X10Mm Hexalobe","40006692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","181.47","181.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm Hexalobe","40006693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","181.47","181.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L6Mm Dia2Mm Cort Ss","40006694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.13","83.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X55Mm Dst Tib","40006695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.56","78.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X50Mm Canc Hex","40006696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.27","77.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X46Mm Mtphseal","40006697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X48Mm Mtphseal","40006698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X30Mm Cort Ft","40006699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X30Mm Dst Tib","40006700","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X45Mm Dst Tib","40006701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.56","78.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm Cort Ft","40006702","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.56","78.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X18Mm Cort Ft","40006703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X75Mm Cort Hex","40006704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.32","77.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X55Mm Pelv Cort","40006705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","66.8","66.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X28Mm Tib Cort Ft","40006706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X16Mm Tib Cort Ft","40006707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X60Mm Tib Cort Ft","40006708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X70Mm Tib Cort Ft","40006709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","53.07","53.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X34Mm Tib Cort Ft","40006710","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X50Mm Cort Hex Dr","40006711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X22Mm Canc Hex Hd","40006712","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","52.52","52.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Canc Hex Hd","40006713","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X22Mm Canc Ft Lok","40006714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.14","731.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Lat Ant 11 H","40006715","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1352.48","1352.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od54Mm Id28Mm Fem","40006716","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","912.61","912.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L100Cm R Cor 3","40006717","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","28.04","28.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ul 400-4 Fnsh Dev Packaged St","40006718","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","5109","5109","","","","","","","","","","","","","Gross Charge Type: Standard"
"3Mmx32Cm Ss Coat W/Utl Hrd","40006719","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","3864.5","3864.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card 3 Chmbr Df1 Conn Hi","40006720","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","18602","18602","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L80Cm Blln 8Mm Dia L4Cm","40006721","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1295.6","1295.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emb Vena Cava Fltr Jug Subclav","40006722","CDM","278","RC","C1880","HCPCS","","","facility","both","","","","2646.5","2646.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dia0.035In 24Mm Pgtl Rf Wire","40006723","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","1611.6","1611.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omniwire 185 Cm Str Tip","40006724","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1121.8","1121.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace L53Cm R Av Steroid","40006725","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"L17.5Cm Ablat Rad W2.1Xl29Mm","40006726","CDM","272","RC","C2618","HCPCS","","","facility","both","","","","3340.5","3340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card Sgl Chmbr Df4 Conn","40006727","CDM","275","RC","C1722","HCPCS","","","facility","both","","","","14410","14410","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Hexapolar D-F Crv","40006728","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","4735.65","4735.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L10Cm Dst D12Mm","40006729","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7338.62","7338.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Iab Ult 8 40Cc","40006730","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1540.5","1540.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Crd 80Gm W51Xh68Mm D13Mm","40006731","CDM","275","RC","C1721","HCPCS","","","facility","both","","","","26986","26986","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth 6Fr L10Cm Dil","40006732","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","635.25","635.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X35Mm Canc Hex Hd","40006734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.26","48.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X50Mm Prox Fem","40006735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","514.71","514.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X36Mm Hindfoot Cort","40006736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X76Mm Hindfoot Cort","40006737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","241.82","241.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X65Mm 2 Cor Tib","40006738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","266.24","266.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uret Stnt 6Fr L22Cm Axxcess","40006739","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","335.71","335.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uret Stnt 6Fr L26Cm Axxcess","40006740","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","335.71","335.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 9H Str 124Mm Ss Lcp","40006741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","635.84","635.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Canc Cann","40006742","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","359.1","359.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X48Mm Canc Cann","40006743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X20Mm Cort Ft Lok","40006744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","205.88","205.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X20Mm Canc Hex Hd","40006745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.26","48.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X24Mm Canc Hex Hd","40006746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.26","48.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Canc Hex Hd","40006747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.49","49.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Compr Canc","40006748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.49","49.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L150Cm Od.038In Std L3Cm","40006749","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","441.19","441.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Bone W/ Arthscp Del Sys","40006750","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1580","1580","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Tend 8 For Regeneten","40006751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","948","948","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X45Mm Fib Cort","40006752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","216.47","216.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext L175Mm Dia5Mm Thrd","40006753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","222.85","222.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obt Shth 8Fr L0.105In Hemstas","40006754","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","267.75","267.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hum Dia40Mm +3Mm Tapr Offset","40006755","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1654.28","1654.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im Sm 10Mm X 150Mm L Ti","40006756","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5167.69","5167.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Fem Rg Dia10Mm L400Mm","40006757","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2962.69","2962.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Suct L135Mm Dia4Mm 90-S","40006758","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 8Mm Full For Acss","40006759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2765","2765","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Ant Cerv 3.5X18Mm","40006760","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","430.5","430.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Thor Rib 20 H Crss","40006761","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1451.63","1451.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rib 40 H Y Shp Lok","40006762","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2577.38","2577.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Thor Rib 32 H Lev 1","40006763","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","268.8","268.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L7Mm Dia2.3Mm Thor","40006764","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2030.14","2030.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lng Y Rig 2.3 Mm Scr 39 H","40006765","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2735.11","2735.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dbl Ld Knee Fibertak W/ Ndl","40006766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892.5","892.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 10 H Str Thck 1.8Mm","40006767","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1025.42","1025.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Strnl Thor 2.3Mmx9Mm","40006768","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.23","101.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrwdriver Asd Maxdrive 2.0 St","40006769","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","288.75","288.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Level 1 Thor St Plt Rib Lok X","40006770","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1715.5","1715.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Rib Ti 2Mmx12Mm Lev 1","40006771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","284.13","284.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rib St 32 H 1.5Mm X","40006772","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2601.19","2601.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia9Mm Nk 125Dg","40006773","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2748.75","2748.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L60Mm D5.0Mm","40006774","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L80Mm D6.0Mm","40006775","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2686","2686","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coronary Imag Catheters","40006776","CDM","278","RC","C1753","HCPCS","","","facility","both","","","","1256.1","1256.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coronary Imaging Catheters","40006777","CDM","278","RC","C1753","HCPCS","","","facility","both","","","","1256.1","1256.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L200Mm Dia10Mm Dst Bnd","40006778","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2833.11","2833.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 22Mm X 4Cm 9Fr X 100Cm","40006779","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1197.64","1197.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl R 16 H Crv","40006780","CDM","C1713","HCPCS","","","","","facility","both","","","","2900.96","2900.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 R Nar Cr","40006781","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz C-D Fem Sz","40006782","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 111Mm Sz 8 Hi Offset","40006783","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L50Mm Dia12.5Mm St Ti","40006784","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","809.63","809.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun Clip Raney","40006787","CDM","272","RC","","","","","facility","both","","","","430.3","430.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex Slf Tpng 2.7Mm","40006788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.32","121.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gun Clip Raney 10-Clip","40006789","CDM","272","RC","","","","","facility","both","","","","153.75","153.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 113Mm Sz 9 Hi Offset","40006790","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Bone Marrow Aspiration","40006791","CDM","272","RC","","","","","facility","both","","","","1429.31","1429.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syr Bone Marrow Aspiration","40006792","CDM","272","RC","","","","","facility","both","","","","446.25","446.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Sonopet Str Tip","40006793","CDM","272","RC","","","","","facility","both","","","","2108.75","2108.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Sonopet Barracuda Tip","40006794","CDM","272","RC","","","","","facility","both","","","","2057.5","2057.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing - Transparent Wound","40006796","CDM","272","RC","A6257","HCPCS","","","facility","both","","","","110.08","110.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"H18Mm L Knee Polyeth Cr Fix","40006798","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 3Mmx38Mm Zotarolimus","40006799","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2796.85","2796.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40006800","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6708","6708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligasure Precise","40006802","CDM","272","RC","","","","","facility","both","","","","1360","1360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proced Ventral Patch 4.3 X 4.3","40006804","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2617.88","2617.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proceed Ventral Patch 6.4X6.4","40006805","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3129.75","3129.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Proceed 4X6 Oval","40006806","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2574","2574","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone Simplex Gentamicin","40006807","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","394.33","394.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bone Simplex 20Ml 40Gm","40006808","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","143","143","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dermal Cortiva 16 X 20 C","40006809","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","11436.48","11436.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Transcarotid L30Mm D9Mm","40006825","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3537","3537","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Orthoblend 10Cc","40006826","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4205.91","4205.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Grafton Putty 10Cc","40006827","CDM","278","RC","","","","","facility","both","","","","3479.05","3479.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Uro Acc 10F X 12F Forte","40006831","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","257","257","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Uret 10Fr 2 Lum Acc 50Cm","40006832","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","161.54","161.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 2.4Mm","40006834","CDM","272","RC","","","","","facility","both","","","","1396.5","1396.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Access Uropass 30Cm","40006838","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","1587.6","1587.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Access Uropass 24Cm","40006839","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","1587.6","1587.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Lag Cort","40006841","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.8","877.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 12Mm R Fix Bear Med Cong","40006843","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Lum Por Ti 20Deg","40006845","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cross Conn Spnl L35Mm Dia3.5Mm","40006847","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","677.44","677.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh-Vicryl Knittred 15X15Cm","40006849","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1090","1090","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh-Vicryl Woven 15X15Cm","40006850","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","872","872","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X30Mm Post Crv","40006853","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.51","1338.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Powerport Slim 6Fr","40006854","CDM","278","RC","C1788","HCPCS","","","facility","both","","","","2505.61","2505.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X34Mm Post Crv","40006855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1338.51","1338.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Derm Mtrx Alloderm 8 X 1","40006857","CDM","636","RC","Q4116","HCPCS","","","facility","both","","","","14963","14963","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thermasplint Medium","40006859","CDM","272","RC","","","","","facility","both","","","","77","77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thermasplint Large","40006860","CDM","272","RC","","","","","facility","both","","","","96.25","96.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Juggernaut 3-0 1.4Mm","40006862","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1950.25","1950.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bag Pressure Infusor 30,000Ml","40006863","CDM","270","RC","","","","","facility","both","","","","225.98","225.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 2.8Mm 324.314","40006864","CDM","272","RC","","","","","facility","both","","","","729.42","729.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 4.3Mm 324.213","40006865","CDM","272","RC","","","","","facility","both","","","","766.5","766.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp 4 Position Lg Pin 390.01","40006870","CDM","272","RC","","","","","facility","both","","","","402","402","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 4.8 X 45Mm Sul","40006871","CDM","272","RC","","","","","facility","both","","","","731.06","731.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire 2.5Mm 292.26","40006872","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","447.85","447.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Proceed 25Cm X 33.5Cm","40006875","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","6758.38","6758.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Proceed 6 X 8","40006876","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2736.5","2736.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Ultrapro 2 X 4","40006877","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","282","282","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dynabunion 4D Min-Incis Bunion","40006878","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2607","2607","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plug Ultrapro Small 3Cm","40006892","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","590","590","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 1.8Mm  02.210.094","40006897","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","561.8","561.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.016","40006900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","780.55","780.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.018","40006901","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","789.66","789.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.022","40006902","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","581.28","581.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.028","40006903","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.25","556.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.030","40006904","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.25","556.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.032","40006905","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","445","445","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 2.7 02.211.048","40006906","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","556.25","556.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lcp 02.111.730S","40006907","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2867.5","2867.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Skin 35W 1164","40006910","CDM","272","RC","","","","","facility","both","","","","55","55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Va Lcp 2.4Mm 02.115.630","40006912","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1535.68","1535.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.025","40006921","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","807.05","807.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.026","40006922","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.027","40006923","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","501.38","501.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.028","40006924","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","807.05","807.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.029","40006925","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","473","473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.030","40006926","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","626.73","626.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Recon 6.5Mm 04.003.032","40006927","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","591.25","591.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Articlip Flex 35Mm","40006932","CDM","272","RC","","","","","facility","both","","","","2373.4","2373.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Articlip Flex 40Mm","40006933","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Articlip Flex 45Mm","40006934","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2504.25","2504.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Sealant Tiseel Fibrin 10Ml","40006935","CDM","278","RC","","","","","facility","both","","","","1263.75","1263.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube T 8Fr","40006942","CDM","272","RC","","","","","facility","both","","","","1368.94","1368.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ball Tip Bugbee 6Fr","40006943","CDM","272","RC","","","","","facility","both","","","","374.24","374.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ball Tip Bugbee 5Fr","40006944","CDM","272","RC","","","","","facility","both","","","","271.3","271.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 10Mm","40006945","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","80","80","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Schanz 4.0Mm","40006946","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","656.53","656.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann 4.0Mm X 36Mm","40006948","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","460.78","460.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia Rt 5In X 3In","40006952","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","592","592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 4.0Mm X 50Mm","40006963","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","151.13","151.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Va Lcp 02.107.302","40006965","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2247","2247","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 2.4Mm","40006967","CDM","272","RC","","","","","facility","both","","","","578.81","578.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Va Lck Rt 3.5 12H","40006971","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3587.85","3587.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Var Ang 3.5Mm 02.127.110","40006973","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","548.55","548.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Var Ang 3.5Mm 02.127.112","40006974","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","434.7","434.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Tap 5Mm","40006981","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1044.75","1044.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Tap 6Mm","40006982","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1044.75","1044.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Tap 8Mm","40006983","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1044.75","1044.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Tap 12Mm","40006984","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1044.75","1044.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Emergency 10","40006990","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","387.5","387.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Emergency 12","40006991","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Emergency 14","40006992","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","528.94","528.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tension Band 04.503.701","40006997","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079","1079","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tension Band 04.503.703","40006998","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1232.7","1232.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tension Band 04.503.702","40007002","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1841.05","1841.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tension Band 04.503.704","40007003","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1232.7","1232.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Adaption 20H 04.503.706","40007005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1980","1980","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007006","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1442.5","1442.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Band","40007007","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1442.5","1442.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcp 2 X 2H","40007008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1779.62","1779.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcp 3 X 3H 04.503.712","40007010","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1533.75","1533.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Crescent 3 X 3H 04.503.7","40007011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1233.2","1233.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcp Angle 3 X 3H","40007012","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1177.67","1177.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Crescent 3 X 3H","40007019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2691.25","2691.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Crescent 3 X 3H 04.503.7","40007023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2038.75","2038.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 6H 04.503.728","40007024","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2614.76","2614.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 12H 04.503.729","40007025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2563.75","2563.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Angle 3 X 3H 04.503.731","40007026","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2797.5","2797.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Recon 20H","40007027","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Drilling 4Mm 04.503.","40007031","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1002.75","1002.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Emergency 6","40007037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","255","255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate L 04.503.335","40007056","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","995.4","995.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1135.05","1135.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Adaption 20H 04.503.346","40007058","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2388.75","2388.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Va Lcp 3.5 8H","40007068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3814.65","3814.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lck 3.5","40007070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","438.84","438.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.0 201.375.97","40007074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","115","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 6","40007077","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1736.25","1736.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 8","40007078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1736.25","1736.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 10","40007079","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1736.25","1736.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 14","40007081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1458.45","1458.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Slf Tap 10","40007082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1458.45","1458.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate L 04.503.364","40007095","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1171.25","1171.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate L 04.503.365","40007096","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1171.25","1171.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Rim 12H","40007097","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1135.05","1135.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Double Y 6H 04.503.378","40007100","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","885","885","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill J-Latch 03.503.404","40007104","CDM","272","RC","","","","","facility","both","","","","451","451","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill J-Latch 03.503.406","40007105","CDM","272","RC","","","","","facility","both","","","","563.75","563.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill J-Latch 03.503.408","40007106","CDM","272","RC","","","","","facility","both","","","","451","451","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill J-Latch 03.503.476","40007109","CDM","272","RC","","","","","facility","both","","","","580.66","580.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Tension Band Thick 03.50","40007113","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","253.75","253.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Angle","40007116","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","19.74","19.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Straight Recon","40007127","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","301.25","301.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Proline Over Under Lrg","40007129","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","92.62","92.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 12Mm","40007130","CDM","272","RC","","","","","facility","both","","","","1259.18","1259.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill J Latch","40007131","CDM","272","RC","","","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Three Fluted 3.2Mm 0","40007132","CDM","272","RC","","","","","facility","both","","","","795.5","795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Three Fluted 32Mm 03","40007133","CDM","272","RC","","","","","facility","both","","","","580.15","580.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Cholangiogram","40007134","CDM","272","RC","","","","","facility","both","","","","188.15","188.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Duraseal 5Ml","40007137","CDM","278","RC","","","","","facility","both","","","","2062.04","2062.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Reamer","40007138","CDM","272","RC","","","","","facility","both","","","","394.92","394.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire 3.2Mm","40007139","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","290.23","290.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Premium Ta-30 48","40007142","CDM","272","RC","","","","","facility","both","","","","976.25","976.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Nitinol Straight Tip 0.03","40007143","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","173.79","173.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Three Fluted 4.2Mm","40007144","CDM","272","RC","","","","","facility","both","","","","497.22","497.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Three Fluted 4.2Mm","40007145","CDM","272","RC","","","","","facility","both","","","","497.9","497.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Three Fluted 5Mm","40007147","CDM","272","RC","","","","","facility","both","","","","463.75","463.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Va 3.5Mm","40007149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3694.95","3694.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp 3.5Mm 4H","40007150","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4921.18","4921.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Neuro Round 2Mm","40007151","CDM","272","RC","","","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Precut Circlage 0.6Mm","40007154","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","44.1","44.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Chest Thoracic Straight 2","40007156","CDM","272","RC","","","","","facility","both","","","","54.6","54.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Chest Thoracic Rt Angle 2","40007157","CDM","272","RC","","","","","facility","both","","","","54.49","54.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureteral 5Fr X 22Cm","40007158","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","438","438","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Precut Circlage 0.5Mm","40007159","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.25","51.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Blake 24Fr Hubless","40007161","CDM","272","RC","","","","","facility","both","","","","184.23","184.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lock 2.7Mm","40007166","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","659.47","659.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007167","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.43","235.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Clavicle Lcp 8H","40007168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2011.8","2011.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp 3.5Mm 7H","40007170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2335","2335","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.756 Screw Cortex Slf-Tpng","40007171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.760 Screw Cortex Slf-Tpng","40007173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.762 Screw Cortex Slf-Tpng","40007174","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.764 Screw Cortex Slf-Tpng","40007175","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.768 Screw Cortex Slf-Tpng","40007177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.774 Screw Cortex Slf-Tpng","40007180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180","180","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.776 Screw Cortex Slf-Tpng","40007181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","190.8","190.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.780 Screw Cortex Slf-Tpng","40007183","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoshield Knitted Cv Fabric 1","40007186","CDM","272","RC","","","","","facility","both","","","","317","317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoshield Knitted Cv Fabric 0","40007187","CDM","272","RC","","","","","facility","both","","","","437.06","437.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lck Va 1.8Mm","40007190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","455","455","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lck Va 1.8Mm","40007191","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364","364","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 6.5Mm","40007192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.25","131.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ex Fix","40007195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1049.55","1049.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"K-Wire 1.8Mm X 150Mm","40007196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","360.02","360.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lck Va 1.8Mm","40007197","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","221.67","221.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lck Va 1.8Mm","40007199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","482.3","482.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm","40007201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","120.75","120.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Clavicle 7H","40007204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1904.7","1904.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex","40007205","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","152.38","152.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Va 2.4 5H","40007207","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1796.68","1796.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Clavicle 6H","40007208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1855.35","1855.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Schanz","40007209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","656.91","656.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Putty Cranios 10Ml","40007210","CDM","278","RC","C9359","HCPCS","","","facility","both","","","","7371.25","7371.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing Set Dual Pump Phaco Pac","40007211","CDM","272","RC","","","","","facility","both","","","","79","79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paste Bone Grafton 10Ml","40007217","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2251.18","2251.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ex Fix 4.0Mm","40007218","CDM","272","RC","","","","","facility","both","","","","2179.74","2179.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thoracic Hydraglide 32Fr","40007219","CDM","272","RC","","","","","facility","both","","","","54.28","54.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gelfilm Neuro 25Cm","40007220","CDM","272","RC","","","","","facility","both","","","","2466.25","2466.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007221","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1482.74","1482.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Kit Biotenodesis","40007222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","859.31","859.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ex Fix","40007223","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1100.13","1100.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ex Fix","40007225","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","863.95","863.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Biotenodesis 8Mm X 23Mm","40007226","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1086.25","1086.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Biotenodesis 8Mm X 12Mm","40007227","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1086.25","1086.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 4Mmx 195Mm","40007228","CDM","272","RC","","","","","facility","both","","","","489.56","489.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lck Va 1.8Mm","40007231","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","238.18","238.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 2.4Mm","40007238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305","305","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 2.4Mm","40007239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.25","320.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 2.4Mm","40007240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","320.25","320.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 2.4Mm","40007241","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305","305","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","505.05","505.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 3.5Mm","40007253","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","520.2","520.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cancellous 6.5Mm","40007270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","105","105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit, Drill Qc","40007319","CDM","272","RC","","","","","facility","both","","","","236.6","236.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit, Drill Qc","40007320","CDM","272","RC","","","","","facility","both","","","","191.1","191.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Carbon Fiber 11.0Mm 350Mm","40007328","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1179.62","1179.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Set Ureteral Navigator","40007331","CDM","272","RC","","","","","facility","both","","","","434.07","434.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extractor Stone Ngage Nitinol","40007332","CDM","272","RC","","","","","facility","both","","","","726.25","726.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cor-Knot Qlu Singles","40007335","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","161.88","161.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Ball 5Mm","40007339","CDM","272","RC","","","","","facility","both","","","","434.4","434.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Loop 15Mm X 12Mm","40007340","CDM","272","RC","","","","","facility","both","","","","465.94","465.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intrvntl Radlgy Proc, 1St Hr","40007343","CDM","360","RC","","","","","facility","both","","","","67105","67105","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc Clgn 8Mm X 40Cm","40007359","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","3358.06","3358.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Applier - Med 11.5","40007363","CDM","272","RC","","","","","facility","both","","","","254.02","254.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Loop 24Fr","40007364","CDM","272","RC","","","","","facility","both","","","","206.25","206.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire Nitinol 0.038 Strai","40007365","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","174.9","174.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire Nitinol 0.038 Curve","40007366","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","138.6","138.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Ultrapro Part Absorb","40007369","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","788.29","788.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Set Split Indwelling","40007371","CDM","272","RC","","","","","facility","both","","","","206","206","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgiclip Prem Disp W/Tiat S-9","40007372","CDM","272","RC","","","","","facility","both","","","","227.85","227.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Fluted 4Mm","40007375","CDM","272","RC","","","","","facility","both","","","","509","509","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Stepped Lg","40007376","CDM","272","RC","","","","","facility","both","","","","1462.13","1462.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Cann 1Mm","40007377","CDM","272","RC","","","","","facility","both","","","","1226.25","1226.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Femoral Denali Vena Cav","40007379","CDM","272","RC","","","","","facility","both","","","","2835","2835","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dialysis Bioflo 15.5F 28","40007383","CDM","272","RC","","","","","facility","both","","","","1150","1150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dialysis Bioflo 15.5F 32","40007384","CDM","272","RC","","","","","facility","both","","","","1150","1150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plastic Minor Surg, 1St Hr","40007390","CDM","360","RC","","","","","facility","both","","","","71803","71803","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plastic Major Surg, 1St Hr","40007391","CDM","360","RC","","","","","facility","both","","","","110654","110654","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Emrg 5Mm Ti Matric Neuro","40007393","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1034.25","1034.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Amplatz Super Stiff","40007394","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","114.71","114.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Protak 5Mm","40007397","CDM","272","RC","","","","","facility","both","","","","948.84","948.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Eea 21Mm","40007398","CDM","272","RC","","","","","facility","both","","","","895","895","","","","","","","","","","","","","Gross Charge Type: Standard"
"Roticulator 55 4.8","40007399","CDM","272","RC","","","","","facility","both","","","","602.44","602.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Eea 25Mm","40007400","CDM","272","RC","","","","","facility","both","","","","746.69","746.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Bentson Str 0.38 X 1","40007401","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","52.5","52.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Amplatz Super Stiff","40007403","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","92.4","92.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biologue 5Ml","40007406","CDM","272","RC","","","","","facility","both","","","","1840.13","1840.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Intnl 28Mmx4.8Mm Ti","40007407","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","737.23","737.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler Eea 31Mm","40007408","CDM","272","RC","","","","","facility","both","","","","895","895","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shunt Cv Pruitt-Inahara","40007409","CDM","272","RC","","","","","facility","both","","","","1733.81","1733.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrieval Stone Optilex Nitino","40007410","CDM","272","RC","","","","","facility","both","","","","744.19","744.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 2.9Mm 310.229","40007411","CDM","272","RC","","","","","facility","both","","","","279.64","279.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Perc 2.5Mm X 300Mm","40007412","CDM","272","RC","","","","","facility","both","","","","581.55","581.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bra Allyson Post Surgical - 1X","40007413","CDM","270","RC","","","","","facility","both","","","","88.75","88.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bra Allyson Post Surgical - 2X","40007414","CDM","270","RC","","","","","facility","both","","","","88.75","88.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bra Allyson Post Surgical - 3X","40007415","CDM","270","RC","","","","","facility","both","","","","91.87","91.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bra Allyson Post Surgical - Xl","40007418","CDM","270","RC","","","","","facility","both","","","","88.75","88.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Pericardial Bovine 10Cm","40007420","CDM","272","RC","","","","","facility","both","","","","1241.25","1241.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Reamer 351.7085","40007423","CDM","272","RC","","","","","facility","both","","","","415.28","415.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 4.0Mm 206.460","40007424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","130","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 3.5Mm 412.110","40007426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","277","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 3.5Mm 412.111","40007427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","277","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 3.5Mm 412.112","40007428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","277","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 3.5Mm 412.115","40007431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","277","277","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 3.5Mm 412.116","40007432","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","293.62","293.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock Ti 412.118","40007436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","264.1","264.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","168.75","168.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Meta 2.7Mm 02.118.510","40007438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","141.75","141.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Meta 2.7Mm 02.118.514","40007440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","135","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Meta 2.7Mm 02.118.520","40007441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","168.75","168.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Pelvic Cortex 3.5Mm 204.","40007446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.5","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Pelvic Cortex 3.5Mm 204.","40007447","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.5","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Pelvic Cortex 3.5Mm 204.","40007448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","102.5","102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Pelvic Cortex 3.5Mm 204.","40007449","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","133.25","133.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Lock 2.7Mm 01-211-042","40007455","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","537.47","537.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007456","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","537.47","537.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Extraction Alexis Conta","40007457","CDM","272","RC","","","","","facility","both","","","","1752.68","1752.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thuederbeat Open Ext Jaw","40007458","CDM","272","RC","","","","","facility","both","","","","1106.43","1106.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thunderbeat 5Mm 35Cm","40007459","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1409.65","1409.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thunderbeat Frnt Grp 5Mm 20Cm","40007460","CDM","272","RC","","","","","facility","both","","","","1458.03","1458.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 2.4 Va Lcp Plate","40007461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1605.58","1605.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 1.3 Lock Screw","40007462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 1.5 Va Lock Screw","40007463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 1.5 Va Lock Screw","40007464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.220 Synthes 1.5 Va Lock","40007465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.218 Synthes 1.5 Va Lock","40007466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.118 Synthes 1.3 Lock Sc","40007467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.014 Synthes 1.3 Cortex","40007470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","161.25","161.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"245.926 Synthes 3.5 Lp Recon P","40007472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1384.69","1384.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"245.920 Synthes 3.5 Lp Recon J","40007473","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1061.25","1061.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.104.032 Synthes 3.5 Lcp X-A","40007474","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3845.63","3845.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.256 Synthes 1.5 Phalang","40007475","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1188.75","1188.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.116 Synthes 1.3 Lock Sc","40007476","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.315 Synthes 2.0 Va Lock","40007479","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","436.86","436.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.211 Synthes 1.5 Va Lock","40007480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.212 Synthes 1.5 Va Lock","40007481","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.010 Synthes 1.3 Cortex","40007484","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","170.93","170.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.104 Synthes Cortex Scre","40007486","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.105 Synthes 1.3 Lock Sc","40007487","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.214.107 Synthes 1.5 Cortex","40007490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","153.75","153.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.216 Synthes 1.5 Lock Sc","40007491","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.215 Synthes 1.5 Va Lock","40007492","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.318 Synthes 2.0 Val Loc","40007494","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.13","412.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.313 Synthes 2.0 Va Lock","40007495","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","436.86","436.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.312 Synthes 2.0 Va Lock","40007496","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","412.13","412.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.311 Synthes  Lock Screw","40007497","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","436.86","436.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.161 Synthes Lock Web Pl","40007498","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1025","1025","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.258 Synthes 1.5 Val Str","40007499","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1083.75","1083.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"422.309 Synthhes Ti Prox Tibia","40007500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3820.69","3820.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007501","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","341.25","341.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.350 Synthes Bone Plate","40007503","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1233.58","1233.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.153 Synthes Bone Plate","40007504","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1363.69","1363.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Midas Burr 4Mm Ball","40007506","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","374.06","374.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.205 Synthes 1.5 Va Lock","40007507","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.209 Synthes 1.5 Va Lock","40007508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.210 Synthes 1.5 Va Lock","40007509","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.69","397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.109 Synthes 1.3 Lock Sc","40007512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","358.31","358.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.359.97 Synthes 2.0 Cortex","40007516","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126.25","126.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"201.360.97 Synthes 2.0 Cortex","40007517","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","133.83","133.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007518","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126.25","126.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doppler Probe - 280Mm","40007520","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","570.94","570.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"422.308 Synthes Proximal Tibia","40007521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4528.75","4528.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.154 Synthes 1.3 Lock Pl","40007522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1181.25","1181.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.157 Synthes 1.3 Lock Pl","40007523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1181.25","1181.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.363 Synthes 2.0 Meta Pl","40007524","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1914.94","1914.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.214 Synthes 1.5 Va Lock","40007525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","408.19","408.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.115.131 Sysnthes Va Lcp Pla","40007526","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1118.75","1118.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.127.150 Synthes Lcp Screw","40007527","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.38","480.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.0 Cannulated Long Th 14-34Mm","40007528","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4187.14","4187.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egia 60 Articulation Extra Rel","40007530","CDM","272","RC","","","","","facility","both","","","","1798","1798","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bn Ostbnd Plmr Pwdr","40007531","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","402.68","402.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealant Pleural Progel 4Ml","40007532","CDM","272","RC","C2615","HCPCS","","","facility","both","","","","3643.5","3643.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egia 45 Articulating Extra Rel","40007534","CDM","272","RC","","","","","facility","both","","","","1219.29","1219.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Seed Prost Radioactive","40007539","CDM","278","RC","","","","","facility","both","","","","334.69","334.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc 6X40 Heparin","40007546","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","4097.23","4097.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.7Mm Bio-Pushlock","40007554","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2666.63","2666.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast 15Ftx4In Othgls Fbgls Tpe","40007556","CDM","271","RC","","","","","facility","both","","","","384.56","384.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007558","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","760.99","760.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt 3.5Mm Lcp Hook 3H","40007559","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1130.62","1130.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 2.0 W Depth Mark","40007560","CDM","272","RC","","","","","facility","both","","","","1095.5","1095.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Fibula 2.7/3.5 3H","40007562","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4671.88","4671.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Fibula 2.7/3.5 4H","40007564","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3063.9","3063.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Fibula 2.7/3.5 5H","40007566","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3110.1","3110.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Fibula 2.7/3.5 6H","40007568","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3146.85","3146.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hernia Sys Ultrapro Lg","40007578","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3723.04","3723.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clips Filshiie","40007580","CDM","272","RC","","","","","facility","both","","","","497.44","497.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgiclip Premium Ii M-9.75","40007582","CDM","272","RC","","","","","facility","both","","","","407.92","407.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"V-Loc 2-0 Gr-Gs-22 Wnd Cls Dev","40007586","CDM","272","RC","","","","","facility","both","","","","152.33","152.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allograft Vip","40007588","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3721.2","3721.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allograft Vip Cancellous","40007590","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3721.2","3721.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dissector Balloon Oval","40007594","CDM","272","RC","","","","","facility","both","","","","1507.8","1507.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Kumar Hernia","40007596","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","192.5","192.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Blunt Tip 12Mm","40007598","CDM","272","RC","","","","","facility","both","","","","692.16","692.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia Phys 20X25Cm","40007601","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","8303.75","8303.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia Phys 15X20 Cm","40007602","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","6153.88","6153.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia Phys 10X15 Cm","40007603","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3557.53","3557.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Distract Caspar 14Mm","40007605","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","560.68","560.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealant Hemostat Floseal 10Ml","40007607","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2170.26","2170.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Access Cranial Disp","40007610","CDM","272","RC","A4550","HCPCS","","","facility","both","","","","1827.5","1827.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ventric W/Trocar","40007612","CDM","278","RC","","","","","facility","both","","","","1012.62","1012.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Drn Csf Ext","40007614","CDM","278","RC","","","","","facility","both","","","","1237.5","1237.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Shunt Hakim 55Cm Disp","40007617","CDM","272","RC","","","","","facility","both","","","","2316.25","2316.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Durepair 3X3In","40007621","CDM","278","RC","","","","","facility","both","","","","6394.38","6394.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Durepair 2X2In","40007622","CDM","278","RC","","","","","facility","both","","","","2416.38","2416.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Durepair 4X5In","40007623","CDM","278","RC","","","","","facility","both","","","","13897.4","13897.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mixer W/Cement Bone Kyphx Hv-R","40007634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","873","873","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Nav Spine Prec 100Mm","40007635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1580.49","1580.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Nav Spine Perc 150Mm","40007636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1578.79","1578.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Peritoneal W/Wall Slit","40007638","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","1088.62","1088.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ventric 1.3Id X 2.5Od","40007639","CDM","272","RC","","","","","facility","both","","","","678.56","678.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ventric 15Cm Bar Imp","40007640","CDM","272","RC","","","","","facility","both","","","","917.5","917.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ventric 23Cm","40007641","CDM","272","RC","","","","","facility","both","","","","698.92","698.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Strata Ii Reg","40007643","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","16995.66","16995.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Sonopet Micro 25Khz (Cs/5)","40007644","CDM","272","RC","","","","","facility","both","","","","2263.1","2263.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Cvc 8Fr Dual Lumen","40007648","CDM","272","RC","","","","","facility","both","","","","433.13","433.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 1.8 Va Lck Btr Strdrv 20M","40007650","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","661.2","661.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 2.4 Va Lck Slt Strdrv 12M","40007656","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","901.98","901.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 2.4 Va Lck Slt Strdrv 14M","40007658","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","897.89","897.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 2.4 Va Lck Slt Strdrv 18M","40007659","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","908.85","908.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 2.4 Va Lck Slt Strdrv 20M","40007660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","912.27","912.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw 2.4 Va Lck Slt Strdrv 22M","40007661","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.89","890.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureth 7X24 Yr Long","40007664","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","542","542","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flute Full Rnd W/Tro 15Fr","40007665","CDM","272","RC","","","","","facility","both","","","","87.45","87.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Pt Tracker Non Invasiv","40007670","CDM","272","RC","","","","","facility","both","","","","535.34","535.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro - Stylet","40007671","CDM","272","RC","","","","","facility","both","","","","1013.63","1013.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Physiomesh Open 10X10","40007672","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","827.56","827.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Ultrapro Advanced 10X15","40007673","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","213.85","213.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Secure Strap - Open Fixation D","40007674","CDM","272","RC","","","","","facility","both","","","","651.64","651.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Vitoss Ba 10Cc","40007680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","10077.11","10077.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Vitoss Ba 1.2Cc","40007681","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2304.25","2304.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar, First Entry","40007685","CDM","272","RC","","","","","facility","both","","","","934.44","934.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pouch 34.5Cm 10Mm E-Ctch Gld","40007686","CDM","272","RC","","","","","facility","both","","","","349.09","349.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plasma Wand Procise Xp","40007688","CDM","272","RC","","","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wand Procise Xp Plasma","40007690","CDM","272","RC","","","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wand Ent Procise Max","40007692","CDM","272","RC","","","","","facility","both","","","","990","990","","","","","","","","","","","","","Gross Charge Type: Standard"
"310.31 Synthes 3.2Mm X 145Mm D","40007695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.21","335.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole Cover Ulp 24Mm Neuro","40007706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1031.1","1031.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carter Thomason Closure System","40007707","CDM","270","RC","","","","","facility","both","","","","469.32","469.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro 12Mm Straight Plate","40007708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","332.5","332.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Adaption Plate 20 Hole","40007709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1691.55","1691.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Adaption Plate 5 Hole","40007710","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1470.41","1470.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Adaption Plate 7 Hole","40007711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1029","1029","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Box Plate 10Mmx16Mm","40007712","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1167.5","1167.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Box Plate 14Mmx14Mm","40007714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1009.49","1009.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 12Mm","40007715","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1652.05","1652.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 12Mm For","40007716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","983.85","983.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 15Mm","40007717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1633.93","1633.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 17Mm","40007718","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1673.37","1673.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 17Mm For","40007719","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1211.41","1211.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 24Mm","40007720","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1622.74","1622.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Burr Hole Cover 24Mm For","40007721","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.53","1241.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Contour Mesh 100Mm X100M","40007722","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","8141.25","8141.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Contour Mesh 100Mmx100Mm","40007724","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","5576.13","5576.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Contour Mesh 38X45Mm","40007726","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","6275.75","6275.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Cranial Plate 12Mm 2H","40007727","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","433.97","433.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Double Y Plate 6Hx18Mm","40007729","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1640.42","1640.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Double Y Plate 6Hx21Mm","40007730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1547.57","1547.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Emergency Screw 3Mm 5 Pk","40007732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1823.75","1823.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Emergency Screw 4Mm 5 Pk","40007734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6275.75","6275.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Screw Self Drilling 3Mm","40007736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","366.82","366.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Screw Self Drilling 4Mm","40007737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","513.52","513.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Screw Self Drilling 4Mm","40007738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5799.53","5799.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Screw Self Drilling 4Mm","40007739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2513.13","2513.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Straight Plate 4 Hole","40007743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","479.45","479.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro X Plate","40007749","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1547.57","1547.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Y Plate 5 Hole","40007750","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1547.57","1547.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginal Sling Mid-Ureth Adv Fi","40007751","CDM","270","RC","A4565","HCPCS","","","facility","both","","","","3572.5","3572.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Spy Elite","40007755","CDM","278","RC","","","","","facility","both","","","","7970.63","7970.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 1.5Mm X 96Mm","40007760","CDM","272","RC","","","","","facility","both","","","","699.8","699.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 1.8Mm Oc 110M","40007761","CDM","272","RC","","","","","facility","both","","","","636.13","636.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 360Mm","40007763","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3987.5","3987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 320Mm","40007766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3349.5","3349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 340Mm","40007767","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3987.5","3987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 380Mm","40007768","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3987.5","3987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 420Mm","40007769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5494.78","5494.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 10Mm X 460Mm","40007771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3349.5","3349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007774","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3190","3190","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 11Mm X 360Mm","40007775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3349.5","3349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 11Mm X 380Mm","40007776","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3349.5","3349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 11Mm X 400Mm","40007777","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5494.78","5494.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 12Mm X 360Mm","40007784","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3349.5","3349.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 12Mm X 380Mm","40007785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5183.75","5183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 12Mm X 400Mm","40007786","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5183.75","5183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Cann Fem Ti 12Mm X 420Mm","40007787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3987.5","3987.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.4 Va-Lcp 2Cl Vlr D6H L","40007793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4035.29","4035.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.4 Va-Lcp 2Cl Vlr D6H R","40007794","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4180.31","4180.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.4 Va-Lcp 2Cl Vlr D6H R","40007795","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4035.28","4035.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.4 Va Lck Strdrv 10Mm","40007797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","435.31","435.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.4 Va Lck Strdrv 16Mm","40007798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","444.35","444.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.4 Va Lck Strdrv 26Mm","40007799","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","424","424","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007800","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","723.45","723.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Conical Slf Tpn 70Mm","40007801","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","720.04","720.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lok 3.5 X 80Mm Self Ttap","40007806","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409","409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lok 3.5 X 85Mm Self Ttap","40007807","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","409","409","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 32Mm","40007810","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100.8","100.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 28Mm","40007812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","101.76","101.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 38Mm","40007813","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","103.82","103.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 36Mm","40007814","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","106.85","106.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 34Mm","40007815","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100.8","100.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath, Ureth Acc 12/14 X 28","40007817","CDM","270","RC","A4270","HCPCS","","","facility","both","","","","521.72","521.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent, Uret 7Fr X 26Cm Dp","40007818","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","556.25","556.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent, Uret 5Fr X 24Cm Dp","40007819","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","455.68","455.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath, Ureth Acc 11/13 X 36","40007820","CDM","270","RC","A4270","HCPCS","","","facility","both","","","","506.96","506.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath, Ureth Acc 12/14 X 36","40007822","CDM","270","RC","A4270","HCPCS","","","facility","both","","","","496.88","496.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Talc Powder Sterile 5Gm Vial","40007823","CDM","272","RC","","","","","facility","both","","","","2821.25","2821.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 55Mm 4Mm Ss P/T Lc Dcp","40007825","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","156","156","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade, Inferior Turbinate 2.9M","40007826","CDM","272","RC","","","","","facility","both","","","","691","691","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ent Propel","40007828","CDM","636","RC","J7402","HCPCS","","","facility","both","","","","2561","2561","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 35Mm 3.5Mm Ss St Lck","40007832","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","159.12","159.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 2.7Mm X 40Mm","40007833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100.8","100.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bag Drain Csf Replacement","40007835","CDM","272","RC","","","","","facility","both","","","","137.5","137.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 3.5Mm X 42Mm","40007837","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","161.62","161.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.0Mm Imf","40007838","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2470","2470","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 3.5Mm X 48Mm","40007839","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","161.2","161.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 3.5Mm X 44Mm","40007840","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","160.68","160.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.0Mm Imf 12Mm","40007841","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1398.75","1398.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mandible Ti Matrix 12H","40007843","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2781.45","2781.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Angle Lock 3.5Mm X 56","40007844","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","510.88","510.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Val Lcp Prox Tb Pl 6H","40007845","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4024.65","4024.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 3.5Mm X 44Mm","40007846","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","501.17","501.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cortex 3.5Mm X 46Mm","40007847","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","161.85","161.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Angle Lock 3.5Mm X 85","40007848","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","646.57","646.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 3.5Mm X 56Mm","40007850","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","662.02","662.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Angle Lock 3.5Mm X 70","40007858","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","846.3","846.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 3.5Mm X 54Mm","40007859","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","662.02","662.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Va Angle Lock 3.5Mm X 54","40007861","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.2","657.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 3.5Mm X 46Mm","40007862","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","499.55","499.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Nim Emg Et Sz 7","40007865","CDM","272","RC","","","","","facility","both","","","","1221.65","1221.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Trnqt 12","40007866","CDM","271","RC","","","","","facility","both","","","","77.5","77.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Trnqt Xlng 42 X 4 Lg 1","40007867","CDM","271","RC","","","","","facility","both","","","","80.6","80.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Trnqt Std 18 X 4 Arm 1","40007868","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","79.58","79.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Trnqt Lng 34 X 4 Lg 1 Fil","40007869","CDM","271","RC","","","","","facility","both","","","","79.88","79.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cuff Trnqt Std 24 X 4 Lg 1 Fil","40007870","CDM","271","RC","","","","","facility","both","","","","80.41","80.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Malecot 14Fr 20Cm","40007874","CDM","272","RC","","","","","facility","both","","","","147.08","147.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Malecot 16Fr 20Cm","40007875","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","138.75","138.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Malecot 20Fr 20Cm","40007876","CDM","272","RC","","","","","facility","both","","","","138.75","138.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Malecot 22Fr 20Cm","40007877","CDM","272","RC","","","","","facility","both","","","","138.75","138.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 8 Hole Lcp Synthes 241.9","40007885","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2999","2999","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Lock 2.7 Va Synthes 02.2","40007892","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.18","657.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Locking 5.0 Synthes 422.","40007893","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","932.75","932.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 4.5 Synthes 2","40007899","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","897.49","897.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 4.5 Synthes 2","40007900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","897.49","897.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 4.0 Synthes 2","40007901","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","554","554","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 4.0 Synthes 2","40007902","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","900.25","900.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 4.0 Synthes 2","40007903","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","554","554","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cannulated 6.5 Synthes 2","40007904","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","903.75","903.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureteral 6 X 20 Double P","40007905","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","462.5","462.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureteral 6 X 30 Double P","40007906","CDM","278","RC","C1758","HCPCS","","","facility","both","","","","462.5","462.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.54 Synthes Schanz Screw","40007913","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.55 Synthes Scanz Screw","40007914","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.74 Synthes Schanz Screw","40007916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.75 Synthes Scanz Screw","40007917","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.76 Synthes Schanz Screw","40007918","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"390.004 Synthes Clamp Lg Multi","40007919","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1454.25","1454.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"390.010 Synthes Clamp Lg Pin","40007920","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1832.76","1832.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"390.037 Synthes Clamp Combo","40007921","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1285.25","1285.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"394.82 Synthes Rod Carbon Fibe","40007922","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","651.11","651.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.56 Synthes Clamp 4.0Mm","40007923","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","838.69","838.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.57 Synthes Clamp 4.0Mm","40007924","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","838.69","838.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.58 Synthes Nut Spring Load","40007925","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","111.25","111.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.70 Synthes Connecting Bar","40007926","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.71 Synthes Connecting Bar","40007927","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.72 Synthes Connecting Bar","40007928","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.73 Synthes Connecting Bar","40007929","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.74 Synthes Connecting Bar","40007930","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.75 Synthes Connecting Bar","40007931","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.76 Synthes Connecting Bar","40007932","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.77 Synthes Connecting Bar","40007933","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"395.90 Synthes Connecting Bar","40007934","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","121.25","121.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Adv Cemt Stem Ext Sz13","40007935","CDM","272","RC","","","","","facility","both","","","","4278.75","4278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar 22Mm Liner X40","40007936","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","651","651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar 22Mm Liner X42","40007937","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","846.3","846.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar 28Mm Liner X44","40007938","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","846.3","846.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar 28Mm Liner X47","40007939","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","651","651","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Adv Cemt Stem Sz 12","40007940","CDM","272","RC","","","","","facility","both","","","","4075","4075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Adv Cemt Stem Sz 14","40007941","CDM","272","RC","","","","","facility","both","","","","4075","4075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Applicator Tip Spray Progel","40007943","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","305.42","305.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40007944","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.55","335.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.30 Synthes Schanz Screw 4.","40007945","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.43 Synthes Schanz Screw","40007946","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.44 Synthes Schanz Screw","40007947","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.45 Synthes Schanz Screw","40007948","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"294.46 Synthes Schanz Screw","40007949","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233.75","233.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gaft Bone Cort Strut 2 X 10Cm","40008010","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1124.55","1124.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Robot Assist Or Maj 1St Hr","40008011","CDM","360","RC","","","","","facility","both","","","","110654","110654","","","","","","","","","","","","","Gross Charge Type: Standard"
"Robot Assist Or Min 1St Hr","40008012","CDM","360","RC","","","","","facility","both","","","","71803","71803","","","","","","","","","","","","","Gross Charge Type: Standard"
"Robot Assist Or Add Min","40008013","CDM","360","RC","","","","","facility","both","","","","708","708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Robotic Surgical System","40008014","CDM","360","RC","S2900","HCPCS","","","facility","both","","","","6655","6655","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L24Mm Dia3Mm","40008015","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L30Mm Dia3Mm","40008016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Fix L36Mm Dia3.5Mm Prtly","40008017","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1790.14","1790.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mobi C Cerv Disc 15X19 H 4.5","40008018","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7074","7074","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Dia3.5Mm Sz 2","40008019","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1110.74","1110.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X3 H St Nar 19.5X51Mm","40008020","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1348.23","1348.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L119Mm 6 H St R Prox","40008021","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2098.78","2098.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm Xl25 Recess","40008022","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","504.5","504.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm L Fem","40008023","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2937.22","2937.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm D11Mm Dst Bend","40008024","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2962.69","2962.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X95Mm St Xl25 Rcss","40008025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.14","500.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pack Battery Repl Rechrg Disp","40008026","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","263.15","263.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X50Mm Star 25 Drv","40008027","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","890.4","890.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L25Mm Dia6.5Mm Ancl","40008028","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal 3.5X12Mm Preferred","40008029","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal 3.5X16Mm Preferred","40008030","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L60Mm Od5.5Mm Ticp","40008031","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 11X120Mm Cdh Versys","40008032","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2826.65","2826.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bplr Od45Mm Id28Mm Hip","40008033","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","906.26","906.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduc Trabecular Mic Byps Sys","40008034","CDM","278","RC","C1783","HCPCS","","","facility","both","","","","3176.75","3176.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 7 H 91Mm Wa Ss Lp","40008035","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","699.03","699.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sm Bend 177Mm Ss Va-Lcp","40008036","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2796","2796","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 8.5X50Mm Post","40008037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5Mmx80Mm","40008038","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 105Mm Sz 5 Hi Offset","40008039","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz H Dia64Mm 13 H","40008040","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4058.38","4058.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Id36Mm Sz H 0Deg","40008041","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Lat Dst R 4 H","40008042","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","872.86","872.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 8-9 Tib Cd/Cr","40008043","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 14Mm R Fix Bear Med Cong","40008044","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm Nk","40008045","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3144.18","3144.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 H10Mm L Vivacit-E Med Cong","40008046","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1366.58","1366.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endoprs L7Cm Dst Dia12Mm","40008047","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5078.87","5078.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 3 Std Ps L","40008048","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Tib Sz B 5Deg Nat","40008049","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1363.7","1363.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-5 H14Mm L Vivacit-E Fix Bear","40008050","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 7 L Nar Cr","40008051","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"H14Mm L Vivacit-E Polyeth Med","40008052","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"H12Mm R Med Cong Fix Bear","40008053","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X70Mm Post","40008054","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum L122Mm Dia17Mm Std","40008055","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4470.38","4470.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H24Mm Od58Mm Id54Mm","40008056","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2495.14","2495.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ang Ml 4Mm X 34Mm Invictus Ct","40008057","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1272.56","1272.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X12Mm Post","40008058","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1374.36","1374.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Cerv Lord 4.0Mmx90Mm","40008059","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 H11Mm L Vivacit-E Med Cong","40008060","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia10Mm 130Deg","40008061","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L300Mm Dia10Mm 130Deg","40008062","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L320Mm Dia10Mm 130Deg","40008063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L340Mm Dia10Mm 130Deg","40008064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia10Mm 130Deg","40008065","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia10Mm 130Deg","40008066","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm 130Deg","40008067","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm 130Deg","40008068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L420Mm Dia10Mm 130Deg","40008069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1775.84","1775.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monarch Bronchoscope System","40008070","CDM","272","RC","C1601","HCPCS","","","facility","both","","","","2684.42","2684.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mic 2.8X28Mm Calcnl","40008071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X16Mm Compr","40008072","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X18Mm Compr","40008073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X20Mm Compr","40008074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X22Mm Compr","40008075","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X24Mm Compr","40008076","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2126.68","2126.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X26Mm Compr","40008077","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Std 4X4.1X28Mm Compr","40008078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.1X30Mm Calcnl","40008079","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","938.52","938.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.1X34Mm Calcnl","40008080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","812.7","812.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evr Stnt L100Mm D22X22Mm","40008081","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22263.45","22263.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evr Stnt L100Mm D24X24Mm","40008082","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22263.45","22263.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Thor L100Mm Dia26X26Mm","40008083","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","22263.45","22263.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evr Stnt L100Mm D28X28Mm","40008084","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","24228.45","24228.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph 18Mmx60Mm Abre","40008085","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3047.75","3047.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 13X130Mm Cdh Versys","40008086","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2826.65","2826.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Bipolar Od50Mm Id28Mm Hp","40008087","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1733.66","1733.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Mt R Ti Ortholoc 3D","40008088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4211.39","4211.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Acss W16Xh12Xl14Mm","40008089","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3081","3081","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal L22Mm Ant Cerv","40008090","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1580","1580","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X17Mm Ant Cerv","40008091","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X18Mm Ant Cerv","40008092","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 4X400Mm Post","40008093","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","682.5","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conn Spnl Dia3.5/4X3.5/4Mm Top","40008094","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1698.5","1698.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"H16Mm L Vivacit-E Polyeth Med","40008095","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Sut Anchor Tsa Eclipse","40008096","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Thorlum 5.5X65Mm","40008097","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 3.5X14Mm Preferrd","40008098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","296.1","296.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc W0.3Xl3In Thk0.36In","40008099","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","220.5","220.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv 3.5Mm Smth Bite","40008100","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 5Fr L200Cm Blln","40008101","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","794.24","794.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"H14Mm R Vivacit-E Polyeth Med","40008102","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox R 10 H L","40008103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2722.4","2722.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acss W16Xh6Xl14Mm","40008104","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3081","3081","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acss W16Xh7Xl14Mm","40008105","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3081","3081","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4X18Mm Ant Cerv","40008106","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili Self Exp 7Fr Cath","40008107","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","270.9","270.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Cort Hex","40008108","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.85","82.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm Cort Hex","40008109","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.85","82.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Suprapectineal R St","40008110","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2458.64","2458.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 99Mm Sz 2 Std Offset","40008111","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L20Mm Od3.5Mm","40008112","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L30Mm Dia4Mm 60Dg","40008113","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L26Mm Dia4Mm Smooth","40008114","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Dia3.5Mm L26Mm","40008115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1828.06","1828.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 8-11 Tib","40008116","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnal Sm W11-13Xh10-18Mm","40008117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1264","1264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W30Xh14Mm D27Mm","40008118","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5764","5764","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal W36Xh14Mm D27Mm","40008119","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5764","5764","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Endoscp 4Mm 40Deg","40008120","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","590.1","590.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia36Mm +0Mm Offset","40008121","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Shv 5Mmx125Mm 6 Flut Brl","40008122","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","388.5","388.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Dia5Mm Blu Agg + Raz","40008123","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","900.6","900.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv D4Mm Brl Bur 12 Flut","40008124","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","110.46","110.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Dia5Mm Auger Bur","40008125","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","156.7","156.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Dia4Mm Red Hub","40008126","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","110.46","110.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 10.35X105Mm Fen Cann","40008127","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","941.05","941.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia36Mm +5Mm Offset","40008128","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X55Mm Post","40008129","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1715.88","1715.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz E Dia52Mm 5 Clus","40008130","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","840","840","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Ef Fem 3-11","40008131","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia32Mm -4Mm Offset","40008132","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extn Stem L30Mm Dia14Mm Tapr","40008133","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","907.55","907.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X18Mm Cort Ft Lok","40008134","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.45","219.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extn Stem Sz C 5Deg R Tib Knee","40008135","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1363.7","1363.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc H13Mm R Fix Bear","40008136","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Lum Por Ti 20 Deg","40008137","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5Mmx40Mm Polyax","40008138","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal 5.5Mmx50Mm Polyax","40008139","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hook Spnal H6.5Mm Post Ti Ally","40008140","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","604.86","604.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hook Spnal H6.5Mm Post Ti Ally","40008141","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","604.86","604.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L120Mm D6.0Mm","40008142","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","2836.1","2836.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Scrw Spinal Lum Pedcl2 Lev","40008143","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2836.1","2836.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X66Mm T25 Stardrv","40008144","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.2","235.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cv 0.62Ml 5Fr Polyur Sl","40008145","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","485.1","485.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-7 Tib Sz","40008146","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 8-9 Tib Cd/Cr","40008147","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Spinal H60Mm Dia18-22Mm","40008148","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","15720","15720","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X18Mm Compr Hdlss","40008149","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orth L100Mm Dia0.8Mm","40008150","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","653.06","653.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem 8-9 Tib Cd/Cr","40008151","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 11 R Nar Cr","40008152","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz E-F Fem Sz","40008153","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz G-H Fem Sz","40008154","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 101Mm Sz 3 Hi Offset","40008155","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 8X99Mm Sz 2 Hi Insgna","40008156","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adhesive Sur 5Ml Incl Syr","40008157","CDM","272","RC","A4364","HCPCS","","","facility","both","","","","5606.08","5606.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge Lum","40008158","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","465.13","465.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Alif 8 Deg 13Mm","40008159","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","18995","18995","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif 5Mm X 20Mm","40008160","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif 5Mm X 30Mm","40008161","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Lum Por Ti 20 Deg","40008162","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Nrv Rep 1-2Mm X 15Mm","40008163","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","3425.64","3425.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protector Nrv 1Cm X 2Cm Mtrx","40008164","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","3394.21","3394.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Stardrv","40008165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Stardrv","40008166","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X24Mm Compr Hdlss","40008167","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","805.29","805.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Oct No1 4X20Mm","40008168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Oct 4X60Mm Post Lrd","40008169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L390Mm Dia10Mm Tib Tn","40008170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2479.59","2479.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ucerv Acs 3D Ti 15Mmx13Mmx6Mm","40008171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ucerv Acs Screw Fxd 3.5Mmx16Mm","40008172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ucerv Acs Scrw Fxd 3.75Mmx16Mm","40008173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.5","262.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L45Cm Dia0.021In Adv Ndl","40008174","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","65.75","65.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X10Mm Polyax","40008175","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1018.71","1018.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.5X36Mm Compr Ft","40008176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","499.8","499.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss L160Mm Achilles","40008177","CDM","272","RC","C1762","HCPCS","","","facility","both","","","","2758.86","2758.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire 2Mm Ss For El Lok Plt","40008178","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","110.46","110.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X65Mm St Hex Drv","40008179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","464.21","464.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X24Mm Compr Cann","40008180","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","520.17","520.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 12Mm Allgrft","40008181","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4716","4716","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.3Mm 1.5Mm Scr Mod Hnd Sys","40008182","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","203.66","203.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L50Mm Dia1Mm Mini Qc","40008183","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","139.89","139.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 1Mm Strykr J Latch","40008184","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","125.87","125.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Cndyl 2X6 H Ss Lcp","40008185","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","976.02","976.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Lat L Cs1 St Ss","40008186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1772.43","1772.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crossconnector Spinal L43-55Mm","40008187","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1768.5","1768.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X55Mm Canc Hex Hd","40008188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.25","47.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X6Mm Dst Rad Ft","40008189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","635.04","635.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.3X12Mm Cort","40008190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","177.55","177.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 109Mm Sz 7 Hi Offset","40008191","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Od48Mm Id28Mm X3","40008192","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X40Mm Canc Hex","40008193","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X50Mm Canc Hex","40008194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 3 Thk10Mm Knee","40008195","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1580","1580","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Sz 32 Thk10Mm","40008196","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1264","1264","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplte Tib Sz3 Ap44Mm Ml67Mm","40008197","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2370","2370","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 2 R Knee Cr","40008198","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2751","2751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Uplr Sz 49Mm Mod Cathcart","40008199","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","997.5","997.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Uplr Sz +5Mm 12/14 Artc","40008200","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","313.22","313.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Fx Ang St 4.3Mmx12Mm","40008201","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 8Mm X 200Mm Blln 5Fr","40008202","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","241.5","241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne W16Xl10Mm Thk0.4Mm 4","40008203","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","310.38","310.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Cement Ostbnd Cplymr 1 40","40008204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","136.76","136.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Orth L91Cm Dia1.8Mm Cocr","40008205","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","82.85","82.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L28Mm Dia3.5Mm Ti","40008206","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plg 30 Absrb Fast Artc Techn","40008207","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1106","1106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone St Std Quadrilatrl","40008208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","935.68","935.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone St Sht Quadrilatrl","40008209","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","848.3","848.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 10 H J-Plt 130Mm","40008210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","921.47","921.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Ulna R 6 H St 131Mm","40008211","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1739.86","1739.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Ulna R 12 H 211Mm","40008212","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1677.82","1677.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Rad X-Artc Vlr L 4X5 H","40008213","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1358.48","1358.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Surg L150Mm Dia1.25Mm L","40008214","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","299.92","299.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 6X4 H Nar 19.5X63Mm Ss","40008215","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1309.98","1309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X5 H Nar 19.5X72Mm Ss","40008216","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1463.84","1463.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X2 H Std 22X45Mm Ss","40008217","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1214.07","1214.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X4 H St Std 22X66Mm Ss","40008218","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1366.4","1366.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 6X10 H St Xln 22X145Mm","40008219","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2331.76","2331.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 7X3 H St Wide 25.5X55Mm","40008220","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1319","1319","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 7X4 H Wide 25.5X68Mm Ss","40008221","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1309.98","1309.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 7X5 H Wide 25.5X77Mm Ss","40008222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1358.48","1358.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 7X7 H St Xln 25.5X110Mm","40008223","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2223.34","2223.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav R 8 H St 120Mm","40008224","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1314.43","1314.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Clav 12 H St 124Mm","40008225","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1314.43","1314.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L100Mm 7 H L Sup","40008226","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1369.01","1369.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Clav Sup R 8H St 115Mm","40008227","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1314.43","1314.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Fib Lat Dst R 3H 73Mm","40008228","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","961.22","961.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Fib Lat L 4 H St 86Mm","40008229","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","875.92","875.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat R 5 H 99Mm","40008230","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","830.35","830.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Fib Lat R 5 H St 99Mm","40008231","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","887.3","887.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Lat R 6 H 112Mm","40008232","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","842.88","842.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat L 6 H 112Mm","40008233","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","533.47","533.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat R 9 H 151Mm","40008234","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","867.93","867.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Rad 2X5 H L-Plt 51Mm","40008235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","964.28","964.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Rad Dst R 6X5 H 57Mm","40008236","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1262.58","1262.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum L 4 H St M 88Mm","40008237","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1715.04","1715.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum R 3H St Sht 75Mm","40008238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1665.4","1665.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum R 7 H Lng 127Mm","40008239","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1603.34","1603.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum R 9 H Xln 153Mm","40008240","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1603.34","1603.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Shrt 75Mm Ss 2.7/3.5Mm","40008241","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1603.34","1603.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum L 1H St Sht 72Mm","40008242","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1715.04","1715.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum L 2 H St M 85Mm","40008243","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1715.04","1715.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Hum Lat L 5H Lng 121Mm","40008244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1603.34","1603.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Tib Med R 6 H St 142Mm","40008245","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2165.23","2165.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne Tib Med R 6 H St 142Mm","40008246","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2118.99","2118.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Med R 10 H 202Mm","40008247","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2307.61","2307.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib R 6 H 112Mm","40008248","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2406.09","2406.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib L 8 H St 142Mm","40008249","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2324.34","2324.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib 4 H St T 72Mm","40008250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1233.25","1233.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib 6 H T Plt 90Mm","40008251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1212.95","1212.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat R 5 H 105Mm","40008252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1243.41","1243.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat R 6 H 118Mm","40008253","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1802.91","1802.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Compr","40008254","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X32Mm Compr Mtph","40008255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.04","107.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X38Mm Compr","40008256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","107.04","107.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R 8 H St Crv 195Mm","40008257","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2296.69","2296.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 8 H St Crv 195Mm","40008258","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2296.69","2296.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 14 H St Crv 301Mm","40008259","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2612.61","2612.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 16 H St Crv 336Mm","40008260","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2661.92","2661.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R 20 H St Crv 405Mm","40008261","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2748.52","2748.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Va Tib Ft","40008262","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.17","281.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X58Mm Va Tib Ft","40008263","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","376.66","376.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L 10 H Sm Bend 177Mm","40008264","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505.66","2505.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Bne L 10 H St Sm Bnd 177Mm","40008265","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2573.39","2573.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R 4 H L Bend 87Mm","40008266","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2153.4","2153.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R 6H St L Bend 117Mm","40008267","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.19","244.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.3X11Mm Va Hnd Thrd","40008268","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.19","244.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X8Mm Va Hnd Thrd","40008269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.43","250.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 H Str 28Mm Ss Va","40008270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","924.08","924.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X7Mm Va Hnd Thrd","40008271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.27","259.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Cort Hex","40008272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","66.64","66.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X12Mm Cort Ft St","40008273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","96.73","96.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin L28Mm Dia1.8Mm Ss Bttrs Va","40008274","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","226.44","226.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X36Mm Va Ank Ft","40008275","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.43","235.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X4Mm Va Cort Ft","40008276","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","124.59","124.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X13Mm Va Cort Ft","40008277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","126.45","126.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X12Mm Condyle Va","40008278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","519.48","519.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X14Mm Condyle Va","40008279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","519.48","519.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X26Mm Condyle Va Ft","40008280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","317.44","317.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X55Mm Condyle Va Ft","40008281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","317.44","317.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X25Mm Condyle Va","40008282","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","431.13","431.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 1Ml Syr Demin","40008283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.38","898.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L35Cm Od4-7Mm Eptfe","40008284","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2275.2","2275.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Saw Std","40008285","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Saw W9Mm Cut Thk2Mm Nar","40008286","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","640.5","640.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cement Bne 20Ml 41Gm Full Dose","40008287","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3361.46","3361.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal Acif 15Mmx6Mmx12Mm","40008288","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2046.1","2046.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Sub 1Cc Dbm Ptty Jr","40008289","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.55","363.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap 0Mm Extn Ti T40 Stardrv","40008290","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.5","275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap D12Mm 15Mm Extn St T40","40008291","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.5","275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia12Mm 20Mm Extn","40008292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.5","275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia16Mm 15Mm Extn","40008293","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","362.12","362.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X80Mm St Recon","40008294","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.97","300.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X100Mm St Recon","40008295","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.97","300.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X105Mm St Recon","40008296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.97","300.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X120Mm Recon Fem","40008297","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","243.08","243.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X130Mm Recon Fem","40008298","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","243.08","243.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth 10Mm Extn Ti Ally","40008299","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth 15Mm Extn G Ti Can","40008300","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338","338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X30Mm St Hum Ft","40008301","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","294","294","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Hum Ft Lok","40008302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","236.12","236.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia12Mm Extn 0Mm G","40008303","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.5","275.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L45Mm Dia12.5Mm Fem G","40008304","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L45Mm Dia12.5Mm St Ti","40008305","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","790.63","790.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L50Mm Dia12.5Mm Fem G","40008306","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill L180Mm Dia2.5Mm Qc","40008307","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","144.65","144.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L55Mm Dia12.5Mm Fem G","40008308","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","732.75","732.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L60Mm Dia12.5Mm Fem G","40008309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","732.75","732.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L65Mm Dia12.5Mm Fem G","40008310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L70Mm Dia12.5Mm St Ti","40008311","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","790.63","790.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L75Mm Dia12.5Mm Fem G","40008312","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L80Mm Dia12.5Mm Fem G","40008313","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","977.85","977.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L85Mm Dia12.5Mm Fem G","40008314","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","791.2","791.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L85Mm Dia12.5Mm St Ti","40008315","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","790.63","790.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L90Mm Dia12.5Mm Fem G","40008316","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L95Mm Dia12.5Mm Fem G","40008317","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L100Mm Dia12.5Mm Fem","40008318","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1007.19","1007.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L320Mm Dia10Mm Univ","40008319","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1662.62","1662.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X50Mm St 2 Cor Tib","40008320","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.11","324.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70Mm St 2 Cor Tib","40008321","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.11","324.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X60Mm 2 Cor Tib","40008322","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.11","324.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70Mm 2 Cor Tib","40008323","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","266.24","266.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X90Mm 2 Cor Tib","40008324","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","266.24","266.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L240Mm Dia7Mm L Tan St","40008325","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1733.06","1733.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L255Mm Dia7Mm L Hum","40008326","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1733.06","1733.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X30Mm Hum Thrd","40008327","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","335.69","335.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X46Mm St Hum Thrd","40008328","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","187.41","187.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X52Mm St Angular","40008329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","284.76","284.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X54Mm St Angular","40008330","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","284.76","284.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 11X90Mm St Fem Nk","40008331","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","736.22","736.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 11X95Mm St Fem Nk","40008332","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","736.22","736.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng25012Ux 2.50X12Rx","40008333","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia5.5Mm","40008334","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L144Cm Blln L8Mm","40008335","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 4.5X40Mm Post","40008336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 8.5X35Mm Post","40008337","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal 60Mm Offset","40008338","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1777.5","1777.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal W9Xh10.5Xl26Mm","40008339","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8187.5","8187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Alif 5.5Mm X 20Mm","40008340","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Lat Lum 5X20Mm","40008341","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L170Mm Dia9Mm Nk 125Dg","40008342","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2243.39","2243.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Colon L60Mm Dia25Mm Cath","40008343","CDM","272","RC","C1876","HCPCS","","","facility","both","","","","3137.45","3137.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix Dia2.4Mm For Prophecy","40008344","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.35","118.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia4.8Mm Tib Crnr","40008345","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","741.3","741.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L102Mm Od3.2Mm Tot Ank","40008346","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","149.91","149.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L144Cm Blln L15Mm","40008347","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","449.4","449.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 6X100Mm","40008348","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L20Mm","40008349","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L60Mm","40008350","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L60Mm","40008351","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia4Mm","40008352","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia6Mm","40008353","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008354","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Shft L144Cm Shth 4Fr","40008355","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3Mm X 40Mm Otw","40008356","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","397.22","397.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008357","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L20Mm","40008358","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008359","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L20Mm","40008360","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008361","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008362","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L100Mm","40008364","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L40Mm","40008365","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008366","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L100Mm","40008367","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008368","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008369","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L150Mm","40008370","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L100Mm","40008371","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L145Cm Blln L40Mm","40008372","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Occl 3.2Fr L135Cm","40008373","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2657.56","2657.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L60Mm","40008374","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L100Mm","40008375","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L220Mm","40008376","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","945","945","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L100Mm","40008377","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","397.22","397.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L60Mm","40008378","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L100Mm","40008379","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","397.22","397.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L220Mm","40008380","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","945","945","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008381","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L200Mm","40008382","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008383","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L200Mm","40008384","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008385","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L100Mm","40008386","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L200Mm","40008387","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008388","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","158.07","158.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008389","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008390","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008391","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","399","399","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L20Mm","40008392","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Shft L75Cm Blln L4Cm","40008393","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L25Mm","40008394","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 2Fr L140Cm Blln L15Mm","40008395","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L15Mm","40008396","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L20Mm","40008397","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.5Mmx 12Mmx145Cm","40008398","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.75Mmx12Mmx145Cm","40008399","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.5Mm X 20Mm X 145Cm","40008400","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 10Mmx20Mm Blln 5Fr Shth","40008401","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","241.5","241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frcp L220Cm Wrk Chn Dia2.8Mm","40008402","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","313.95","313.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 H13Mm L Vivacit-E Med","40008403","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Endscp 165Cm Nit Pt Preld","40008404","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1026.9","1026.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys 20Mm X 60Mm Abre","40008405","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2883.5","2883.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"3D Print Anterior Lumbar Cage","40008406","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","34060","34060","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fixation Screws For Cage","40008407","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2528","2528","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 3.0 Mmx20Mmx145Cm","40008408","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.0Mmx8Mmx145Cm","40008409","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.75 Mmx8Mmx145Cm","40008410","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L10Mm","40008411","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathr Blln 3.0Mm X 8Mm X 145Cm","40008412","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L15Mm","40008413","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.5Mm X 8Mm X 145Cm","40008414","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln  4.0Mm X 8Mm X 145Cm","40008415","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln  3.0Mm X 15Mmx145Cm","40008416","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 3.5Mm X 15Mm X 145Cm","40008417","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.0Mm X 15Mm X 145Cm","40008418","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 3.5Mm X 20Mm X 145Cm","40008419","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 3.5Mm X 8Mm X 145Cm","40008420","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 2Fr L145Cm Shft","40008421","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L20Mm","40008422","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L10Mm","40008423","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 5.0Mm X 8Mm X 145Cm","40008424","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.5Mm X 20Mm X 145Cm","40008425","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.75Mm X 15Mm X145Cm","40008426","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L20Mm","40008427","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.0Mm X 12Mm X 145Cm","40008428","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L15Mm","40008429","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L20Mm","40008430","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.25Mm X 15Mm X145Cm","40008431","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.25Mm X 12Mm X145Cm","40008432","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 3.0Mm X 12Mm X 145Cm","40008433","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L10Mm","40008434","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.5Mm X 15Mm X 145Cm","40008435","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 2.25Mm X 8Mm X 145Cm","40008436","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.5Mm X 15Mm X 145Cm","40008437","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L10Mm Dia2.5Mm","40008438","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1501","1501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.0Mm X 12Mm X 145Cm","40008439","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Shft L75Cm Blln L4Cm","40008440","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008441","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.36","189.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008442","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.36","189.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln 9Mm L4Cm","40008443","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1295.6","1295.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L40Mm","40008444","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","441.4","441.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L10Mm","40008445","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 2Fr L145Cm Dst Shft","40008446","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.5Mm X 12Mm X 145Cm","40008447","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L10Mm","40008448","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L6Mm","40008449","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L210Mm","40008450","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","774.9","774.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L12Mm","40008451","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1155","1155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L40Mm","40008452","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 6Fr L75Cm Blln L6Cm","40008453","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 4.5Mm X 8Mm X 145Cm","40008454","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","157.5","157.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L20Mm","40008455","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L40Mm","40008456","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L20Mm","40008457","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L80Mm","40008458","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L210Mm","40008459","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","774.9","774.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L60Mm","40008460","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L40Mm","40008461","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008462","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L40Mm","40008463","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L80Mm","40008464","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L80Mm","40008465","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L20Mm","40008466","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L100Mm","40008467","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","396.9","396.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L60Mm","40008468","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L80Mm","40008469","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L40Mm","40008470","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cut Blln L10Mm","40008471","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1501","1501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L155Cm Blln 3.5Mm Dia","40008472","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2204.1","2204.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 8Mmx4Cm Otw","40008473","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 6Fr L75Cm Blln L4Cm","40008474","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm Blln L20Mm","40008475","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","184.1","184.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm Blde L6Mm","40008476","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1501","1501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm Blde L10Mm","40008477","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1501","1501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L40Mm","40008478","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","305.55","305.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L40Mm Dia2.5Mm Wrk","40008479","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4345","4345","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L110Cm Blln L4.5Cm D23Mm","40008480","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 8Mm X 40Mm Blln 135Cm","40008481","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 14Mm X 20Mm Blln 135Cm`","40008482","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L30Mm","40008483","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","588","588","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L135Cm Blln L60Mm Dia4Mm","40008484","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4519.5","4519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L135Cm Blln L40Mm Dia3Mm","40008485","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3602.5","3602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od51Mm Id28Mm Fem","40008486","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","911.66","911.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Drill L2.7Mm Univ","40008487","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","803.29","803.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 2X3 H 35Mm Oblq L","40008488","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.36","741.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L42Mm 2X4 H Bilat","40008489","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.36","741.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L40Mm 2X4 H Bilat","40008490","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.36","741.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L400Mm Dia3.2Mm","40008491","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","305.76","305.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autoclv 4Mm X 30 140Mm Spd-Lok","40008492","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","5445.97","5445.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acryl Iol (N-Preld) +22.00D","40008493","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","245.3","245.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 8 L Nar Cr","40008494","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3301.2","3301.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-11 18Mm L Fix Bear Cr","40008495","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl Oblq W9Xh10Xl24Mm","40008496","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5109","5109","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinl 9Mmx28Mmx9.5-14Mm","40008497","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","8187.5","8187.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnal Oct 4X400Mm Post Str","40008498","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","395","395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L260Cm Dia0.035In","40008499","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","569.42","569.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cvr Bur H Dia17Mm Thk0.3Mm Ti","40008500","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","606.9","606.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Bio W10Xl20Cm Ovine Rumen","40008501","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3002","3002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Bio Tiss 30Cm X 25Cm","40008502","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","8515","8515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W10Xl20Cm Thk1.1Mm","40008503","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4480.2","4480.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Biologic Tiss W25 X L30Cm","40008504","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","13755","13755","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dvc Bne Bx Sz 2 10Ga Dia43.4Mm","40008505","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","194.04","194.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Frontier 2Mm X 22Mm","40008506","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 4 Thk11Mm Knee","40008507","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1580","1580","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplte Tib Sz4 Ap46Mm Ml70Mm","40008508","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2370","2370","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 3 L Knee Cr","40008509","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2751","2751","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 120Mm Nk 37Mm Sz 9","40008510","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Id36Mm Sz E 0Deg","40008511","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 111Mm Sz 8 Std Offset","40008512","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav Lat L Cs2 St Ss","40008513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2103.61","2103.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X45Mm Canc Hex","40008514","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.5","131.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Hum 6Mm Mini Shldr Cocr","40008515","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4470.38","4470.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Surg L20In Nit Trcr Tip","40008516","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","200.55","200.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plier Bend 230Mm For 2.7/3.5Mm","40008517","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2329.25","2329.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Alg W6Xl6In Hydrfbr","40008518","CDM","623","RC","A6197","HCPCS","","","facility","both","","","","44.08","44.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L65Mm Od5.5Mm Ticp","40008519","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L75Mm Od5.5Mm Ticp","40008520","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Ft 8 H Str Ortho 3Di","40008521","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1960.94","1960.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector 6Mm X15Mm Axoguard","40008522","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2646.5","2646.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz E-F Fem Sz","40008523","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 4-5 Tib Sz","40008524","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Biologic Tiss 15X15Cm Blu","40008525","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4167.11","4167.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X48Mm Stardrv","40008526","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X46Mm Stardrv","40008527","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L50Mm Dia2.7Mm","40008528","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","116.32","116.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Stardrv","40008529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibergraft Bg Ptty Lg 11Cc","40008530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3340.5","3340.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hip 6 H St 110Mm","40008531","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1036.29","1036.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 13X75Mm St Lag Canc","40008532","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","689.24","689.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Stardrv","40008533","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Stardrv","40008534","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum X-Artc Dst L 6 H","40008535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1984.76","1984.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Fem Sz 6-7 Tib Sz","40008536","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc Tib Sz E-F Fem Sz","40008537","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal L35Mm Dia5Mm Cort","40008538","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1764.92","1764.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Crss Spinal 4Mmx40Mm","40008539","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1422.62","1422.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Cerv Ti 4.0Mm X 70Mm","40008540","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","524.12","524.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W25Xl40Cm Blu Clr","40008541","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4167.11","4167.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Id0.07In Vl3 Crv","40008542","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","144.65","144.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L22Mm Dia1.8Mm Ss Bttr","40008543","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","224.7","224.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protct Pin L0.042In Dia1.1Mm","40008544","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","277.96","277.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Everolimus Drg Elut","40008545","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.0Mm X 20Mm  Synergy Xd","40008546","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","231","231","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 7Fr L100Cm Fl5 Crv","40008547","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","127.16","127.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L260Cm Dia0.035In","40008548","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","374.41","374.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Cath 10Fr L8In","40008549","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","798.88","798.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Lsr 12Fr L50Cm Ld 7.5Fr","40008550","CDM","272","RC","C2629","HCPCS","","","facility","both","","","","4316.45","4316.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant L23Mm 370Ug Mometasone","40008551","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","2449","2449","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L80Cm Dia0.035In","40008552","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","515.97","515.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Dia20-25Cm Wht Poly","40008553","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1263.43","1263.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Had Cath L32Cm Dia14.5Fr","40008554","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","1998.7","1998.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Uro 10/12Fr L24Cm Dil","40008555","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","441.19","441.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endoscp L150Cm D0.038In","40008556","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","441.19","441.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L40Mm D3.5Mm Orsiro","40008557","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Had 16Fr L19Cm Polyur Lt","40008558","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","1998.7","1998.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm D2.75Mm Orsiro","40008559","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm D2.75Mm Orsiro","40008560","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","869","869","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Brst Bx Shp 2 For Us Ss","40008561","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1168.41","1168.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L145Cm Dia0.035In","40008562","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","102.57","102.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Duodenal L90Mm Dia22Mm","40008563","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3082.67","3082.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endoscp L260Cm D0.025In","40008564","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","712.22","712.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hern L Dia3.2In Cir","40008565","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1027","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 12.7X150Mm Sz 9 45Mm","40008566","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2573.82","2573.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Hern Sm Dia1.7In Cir","40008567","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","871.5","871.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 5 L110Mm Dia8.9Mm","40008568","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","147.28","147.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Uro 11/13Fr L46Cm Uret","40008569","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","264.73","264.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia3Mm Plat","40008570","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mm X 16Mm  Synergy Xd","40008571","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.5Mm X 20Mm  Synergy Xd","40008572","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.5Mmx28Mm  Synergy Xd","40008573","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mmx28Mm  Synergy Xd","40008574","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1738","1738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur W7Xl10Cm Sepra Tech","40008575","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2398.44","2398.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Coracoclavicular Lgmnt Acu","40008576","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2392.12","2392.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2.25Mm X 12Mm","40008577","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2Mm X 15Mm","40008578","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 3Mm X 22Mm","40008579","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.25Mm X 26Mm Orsiro","40008580","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.5Mm X 35Mm Orsiro","40008581","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Carotid L30Mm Dia9Mm","40008582","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3152.1","3152.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Carotid L30Mm Dia8Mm","40008583","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3152","3152","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2Mm X 18Mm","40008584","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 3Mm X 35Mm Orsiro","40008585","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.75Mm X 26Mm Orsiro","40008586","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 4.5Mm X 30Mm","40008587","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 4.5Mm X 22Mm","40008588","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 4.5Mm X 18Mm","40008589","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 3Mm X 34Mm","40008590","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 4Mm X 40Mm Orsiro","40008591","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.5Mm X 15Mm Orsiro","40008592","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.25Mm X 30Mm Orsiro","40008593","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2.5Mm X 18Mm","40008594","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","829.5","829.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.25Mm X 22Mm Orsiro","40008595","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.25Mm X 18Mm Orsiro","40008596","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia4.5Mm","40008597","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.75Mm X 15Mm Orsiro","40008598","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.5Mm X 22Mm Orsiro","40008599","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L20Mm Dia3.5Mm","40008600","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1572","1572","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X50Mm Hum Ft Lok","40008601","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","236.12","236.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tray Strl Insrt Instr Bend","40008602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","145.18","145.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X45Mm Compr Hdlss","40008603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1301.32","1301.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X65Mm Compr Hdlss","40008604","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1301.32","1301.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L230Mm Dia3.2Mm","40008605","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","595.35","595.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L230Mm Dia3.2Mm","40008606","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","160.97","160.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Countersink Sur Dia7Mm Cann","40008607","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","732.06","732.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Lng L Med Clmn Fus","40008608","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2706.54","2706.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm T10 Drv Ft","40008609","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm T10 Drv Ft","40008610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm T10 Drv Ft","40008611","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","449.82","449.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm T10 Drv Ft","40008612","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","349.76","349.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm T10 Drv Ft","40008613","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X60Mm Compr Hdlss","40008614","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1301.32","1301.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X45Mm Compr Hdlss","40008615","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","464.57","464.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem Sz 5 L108Mm Nk L35Mm","40008616","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3275","3275","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 2X4 H T Plt 40Mm Ss","40008617","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.42","1022.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L40Mm 2X4 H Bilat L","40008618","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.36","741.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L42Mm 2X4 H Bilat R","40008619","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","741.36","741.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L10Mm Dia2.7Mm Ti","40008620","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.27","546.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia2.7Mm Ti","40008621","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.27","546.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X80Mm Hextstar Drv","40008622","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","842.31","842.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Id36Mm Sz F 0Deg","40008623","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Lsr 12Fr L50Cm Ld 7.5Fr","40008624","CDM","272","RC","C2629","HCPCS","","","facility","both","","","","4316.45","4316.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Dia4Mm Ang Red Hub","40008625","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","144.65","144.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thor 28Fr L15.75In Clr","40008626","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","80.93","80.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia36Mm +2.5Mm Offset","40008627","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz F Dia58Mm 5 Clus","40008628","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.5X80Mm Stardrv","40008629","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L300Mm Dia2.8Mm","40008630","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","220.63","220.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 48Mm 3 Level","40008631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4710.76","4710.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X32Mm Stardrv Rcss","40008632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X28Mm Stardrv Rcss","40008633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X38Mm Stardrv Rcss","40008634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X32Mm Stardrv Rcss","40008635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Stardrv Rcss","40008636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","717.99","717.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Everolimus Drg Elut","40008637","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1896","1896","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 H10Mm L Vivacit-E Med Cong","40008638","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"4-5 16Mm R Fix Bear Cong","40008639","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sz Ef H12Mm R Knee Vivacit-E","40008640","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flexible Cryoprobe, Sgl-Use","40008641","CDM","272","RC","C2618","HCPCS","","","facility","both","","","","963.9","963.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Dura W1Xl1In Ult Pure","40008642","CDM","278","RC","Q4199","HCPCS","","","facility","both","","","","735","735","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Jet Lav 450Ml 0.05% Chg","40008643","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1327.2","1327.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inflatr Endoscp Brl 30Cc 40Atm","40008644","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","420","420","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth Intro 8Fr L10Cm Dil Prtrd","40008645","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","664.86","664.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bi Dir 7Fr Def Cs D-F 12 Pin","40008646","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","957.48","957.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Pta Dia10Mm L40Mm","40008647","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1088.62","1088.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L135Cm L60Mm Dia7Mm","40008648","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4519.5","4519.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L200Mm D5.0Mm","40008649","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2882","2882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vascular L185Cm J Tip","40008650","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1121.8","1121.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L6Cm Od8M","40008651","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1295.6","1295.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lt Dist Mdl Tib 168Mm Ss","40008652","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1957.62","1957.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm Blln L250Mm","40008653","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3043.08","3043.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L180Cm Dia0.035In","40008654","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","453.6","453.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L6Cm Od7M","40008655","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1295.6","1295.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide L130Cm Od1.8/2.6Fr","40008656","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1050","1050","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defibrillator Card 2 Chmbr Df1","40008657","CDM","275","RC","C1721","HCPCS","","","facility","both","","","","16389.41","16389.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln 7Mm Dia","40008658","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1295.6","1295.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace L45Cm R Av Steroid","40008659","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","553","553","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Athrctmy Dia1.25Mm Preconn","40008660","CDM","272","RC","C1724","HCPCS","","","facility","both","","","","3013","3013","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili L60Mm Dia10Mm Cath","40008661","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3153.46","3153.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thorcent 5Fr Nonvalved Cath","40008662","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","510.66","510.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Ld Lok 0.015-0.023In X","40008663","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","2915.1","2915.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Nephstmy 8Fr L25Cm Gwire","40008664","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","848.46","848.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L180Cm Dia0.014In","40008665","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1027","1027","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth Dia12Mm Extn 0Mm G","40008666","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","275.1","275.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vsclr 0.025Inx180Cm Flpy","40008667","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","43.19","43.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L40Mm Dia18Mm Cath","40008668","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1403.62","1403.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L60Mm Dia18Mm Cath","40008669","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1403.62","1403.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L260Cm Dia0.025In","40008670","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","44.92","44.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L200Mm","40008671","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2882","2882","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 45Mm 3 Lev","40008672","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4710.76","4710.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Sur Orth Dia8-13Mm Lng","40008673","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","247.88","247.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcarotid Stnt 9-7Mmx30Mm","40008674","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3732.19","3732.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntr Bioactive Bone Graft 1000","40008675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3602.5","3602.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Alg W2Xl2In Hydrfbr","40008676","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","17.14","17.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 6Fr L10Cm Gwire","40008677","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","218.4","218.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X40Mm Canc Hex Drv","40008678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.52","403.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 12 H 1/3 Tblr 143Mm","40008679","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1001.07","1001.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X16Mm T10 Drv Ft","40008680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X20Mm T10 Drv Ft","40008681","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","244.76","244.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X50Mm Cort Hexalobe","40008682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2636.39","2636.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L200Mm Dia2Mm W/O Thrd","40008683","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","157.41","157.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3Mm Calib","40008684","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","295.47","295.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Surg Dia4Mm Cann W/ Calib","40008685","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","584.01","584.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X80Mm Stardrv","40008686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Sur Drill 1.6X3Mm Dbl","40008687","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","954.48","954.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X130Mm Canc Hex","40008688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.66","452.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thromctmy L130Cm Lightn","40008689","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","7191.9","7191.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Hydrocephalus Prgrmmbl R","40008690","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","6681.47","6681.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Diag 6Fr L125Cm Jl4.0 Crv","40008691","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","111.78","111.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Str Crv 6Fr 125Cm 6 Side H","40008692","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","111.78","111.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide 6Fr Dia0.07In Cls 3","40008693","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","114.65","114.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 6Mm Cann","40008694","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","525","525","","","","","","","","","","","","","Gross Charge Type: Standard"
"G-H H11Mm L Vivacit-E Med","40008695","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Med Dst R 4 H St","40008696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2328.04","2328.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Ext Fix L250Mm Dia5Mm","40008697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","253.66","253.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X55Mm Stardrv","40008698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X65Mm Stardrv","40008699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.17","898.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"E-F H11Mm L Vivacit-E Med Cong","40008700","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2159.2","2159.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.4X80Mm St Fem Nk","40008701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","462.44","462.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemostatic Agnt Surgcel Nu","40008702","CDM","623","RC","A6021","HCPCS","","","facility","both","","","","199.98","199.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Agent Hemstat Surgcel Pwd 3Gm","40008703","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","443.79","443.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Fem 54X41.6X9.5X14Mm","40008704","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2765","2765","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Tib 14X60X36X11X7.8Mm","40008705","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2765","2765","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl Crv W17Xh4.5Mm D14Mm","40008706","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4257.5","4257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl 62Mm Cerv 4 Lev Adm","40008707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4710.76","4710.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Spnl Temp Fix Admiral 2","40008708","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1012.2","1012.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L360Mm Dia10Mm Tib Tn","40008709","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2479.59","2479.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endoscp 0.025Fr L260Cm","40008710","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","712.22","712.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L24Cm Flexima","40008711","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L22Cm Flexima","40008712","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil L110Cm Blln L5.5Cm","40008713","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","617.88","617.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X120Mm Canc Hex","40008714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.66","452.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge 10.2Fr L40Cm Seg L","40008715","CDM","278","RC","C1729","HCPCS","","","facility","both","","","","213.07","213.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L375Mm Dia8Mm Univ Dk","40008716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1456.21","1456.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib L 9 H 151Mm Ti","40008717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","867.93","867.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Bio Tiss Bioindctv 1","40008718","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","3336","3336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Countersink Sur 2X2.4Mm","40008719","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","217.65","217.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 13X70Mm St Lag Canc","40008720","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","731.91","731.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz 2 Ap 42Mm Ml","40008721","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Tib Sz 2 Thk10Mm Knee X3","40008722","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 465Cc Dia13.3Cm","40008724","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implnt Brst 500Cc 13.1Cm 5.3Cm","40008725","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 630Cc Dia14.7Cm","40008726","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcarotid Stnt 8-6Mm X 30Mm","40008727","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3960.11","3960.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcarotid Stnt 8-6Mm X 40Mm","40008728","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3960.11","3960.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcarotid Stnt 9-7Mm X 40Mm","40008729","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3960.11","3960.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 545Cc Dia13.4Cm","40008730","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 630Cc Dia14.2Cm","40008731","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal L20Mm Od4Mm Polyax","40008732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spinal Sz D Hd To Hd","40008733","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1920.5","1920.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 6.5Mm X 45Mm","40008734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Mis Perc 5.5Mm X 55Mm","40008735","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L30Mm Dia9Mm","40008736","CDM","C1713","HCPCS","","","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr X 22Cm Gldex","40008737","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","316.66","316.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern W4Xl6In Polypr Mfil","40008738","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","382","382","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Brst Bx Site 13Cm Ss","40008739","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1140.71","1140.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Brst Bx Shp 3","40008740","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1234.97","1234.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Bx Sitek","40008741","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1234.97","1234.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Dia9Cm Wht Poly Cllgn","40008742","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","549.99","549.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endoscp 0.035In X 450Cm","40008743","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","665.1","665.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge 10.2Fr L60Cm Gwire","40008744","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","358.25","358.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endscp L230Cm Dia0.038In","40008745","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","3195.61","3195.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Uret 5Fr L40Cm Bern","40008746","CDM","272","RC","C1758","HCPCS","","","facility","both","","","","234.75","234.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L60Cm Od8Mm Str Rng","40008747","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2705.4","2705.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X24Mm Cort T8","40008748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","218.63","218.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Cv W1Xl6In Thk1.65Mm","40008749","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","348.8","348.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 7.5Fr L240Cm Blln","40008750","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln Dil 7.5Fr L180Cm","40008751","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreas L10Cm Od7Fr","40008752","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","192.56","192.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L182Cm Dia0.014In","40008753","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1092.7","1092.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7.5Fr 3-4.5-7Atm Es Pyl","40008754","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7.5Fr 3-4.5-8Atm Es Pyl","40008755","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7.5Fr 3-4.5-6Atm Es Pyl","40008756","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Endoscp L180Cm Cath 7.5Fr","40008757","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 6Fr L180Cm Blln","40008758","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","366.12","366.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Endoscp L240Cm Blln L5.5Cm","40008759","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Endoscp L180Cm Cath 7.5Fr","40008760","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","417.14","417.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L90Mm Dia10.35Mm","40008761","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","989.02","989.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Pancreas 4Fr L5Cm 0.035In","40008762","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","170.44","170.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreas 4Fr L4Cm Plas","40008763","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","170.44","170.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Endoscp L180Cm Cath 7.5Fr","40008764","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","501.77","501.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5.8Fr L180Cm Blln","40008765","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","501.77","501.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Retrv 7-6Fr Wrk L200Cm","40008766","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","317.71","317.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5.8Fr L180Cm Blln","40008767","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","501.77","501.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5.8Fr L180Cm Blln","40008768","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","501.77","501.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endscp L480Cm Dia0.035In","40008769","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","336.73","336.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 7Fr L26Cm Percflx","40008770","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","539.35","539.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uro Shth 8-30Fr L35Cm Renal","40008771","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","571.95","571.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 6Fr L120Cm Loop D12-20Mm","40008772","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 6Fr L120Cm Loop D9-15Mm","40008773","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snare 7Fr L120Cm Dia18-30Mm","40008774","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","738.13","738.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X28Mm Hindfoot Cort","40008775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.78","256.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evr Stnt L100Mm D22X22Mm","40008776","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","23623.05","23623.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Port 22X80Mm Slt Bvl Retrct","40008777","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2821.7","2821.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prt Rtrctr Dia.22X70Mm Beveled","40008778","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","28021.7","28021.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Beveled Tube 22 X 90","40008779","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2821.7","2821.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube 80Mm","40008780","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2821.7","2821.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube 90Mm","40008781","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2821.7","2821.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Beveled Tube 22 X 100","40008782","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","2821.7","2821.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Protct","40008783","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gauge Depth Ss","40008784","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","895.55","895.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Lat 9 H St 151Mm","40008785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1041.93","1041.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lig Md Lg Grn Ti 6","40008786","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","38.51","38.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 108Mm Sz 3 Hi Offset","40008787","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2855.7","2855.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X46Mm Sterile Xl25","40008788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","626.63","626.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.5Mm X 12Mm Synergy Xd","40008789","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4Mm X 9Mm Orsiro Mission","40008790","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt L100Mm Dia24X24Mm","40008791","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","23623.05","23623.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Thor L100Mm Dia26X26Mm","40008792","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","23623.05","23623.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stnt L100Mm Dia28X28Mm","40008793","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","25708.05","25708.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X42Mm St Hum Thrd","40008794","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","25708.05","25708.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Thk1Mm 2X2 H R","40008795","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","758.27","758.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"End Cap Ortho 10Mm For Tna","40008796","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","476.6","476.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Lord Cerv 4.0Mmx65Mm","40008797","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.56","556.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Pedcl 4.5Mmx28Mm","40008798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1345.05","1345.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm 6Fr L20Mm D8Mm","40008799","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L12Mm D2.25Mm","40008800","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L12Mm Dia2Mm","40008801","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L12Mm D1.5Mm","40008802","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cor 3X8Mm Otw 143Cm","40008803","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cor 2.25X8Mm Otw","40008804","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L8Mm Dia2Mm","40008805","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L8Mm Dia1.5Mm","40008806","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L8Mm Dia4.5Mm","40008807","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2271.2","2271.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L8Mm Dia4Mm","40008808","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2271.2","2271.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L8Mm Dia3.5Mm","40008809","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2271.2","2271.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L8Mm Dia3Mm","40008810","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2271.2","2271.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia2Mm","40008811","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L60Mm Dia6Mm","40008812","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L60Mm Dia5Mm","40008813","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1007.11","1007.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia9Mm","40008814","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia8Mm","40008815","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L150Mm Dia7Mm","40008816","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L80Mm Dia7Mm","40008817","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008818","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Sur Meas Dir For Im Nai","40008819","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","577.48","577.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Meas Dir For Rfn Adv Rg","40008820","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","710.83","710.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Tib Prox R 4 H Sm","40008821","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2472.94","2472.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 62Mm 4 Lev","40008822","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X50Mm Cort Hexalobe","40008823","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2786.56","2786.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008824","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L60Mm","40008825","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L80Mm","40008826","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Blln L80Mm","40008827","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm Blln L20Mm","40008828","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm 4Fr L80Mm","40008829","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm 4Fr L120Mm","40008830","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm 4Fr L80Mm","40008831","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L80Mm","40008832","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 4Fr L80Cm Blln L20Mm","40008833","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L20Mm","40008834","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L20Mm","40008835","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm Blln L20Mm","40008836","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 4Fr L150Cm L100Mm","40008837","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L80Mm","40008838","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L150Mm","40008839","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 7X40Mm Otw 135Cm","40008840","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 4Fr L135Cm L20Mm","40008841","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm Blln L80Mm","40008842","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L20Mm","40008843","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm Blln L60Mm","40008844","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 7X20Mm Mrail","40008845","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 4Fr L150Cm L100Mm","40008846","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008847","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008848","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008849","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008850","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008851","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2.6X2.3X2.4Fr L144Cm","40008852","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L30Mm Dia2.5Mm","40008853","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L30Mm Dia2.25Mm","40008854","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L30Mm Dia2Mm","40008855","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia4Mm","40008856","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"H13Mm L Knee Polyeth Cr Fix","40008857","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ef/Cr H14Mm L Vivacit-E Polyth","40008858","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 11.5X55Mm","40008859","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4865","4865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dynabunion Std Plt R","40008860","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2755.5","2755.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Motoband Bne Plating Sys","40008861","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1002","1002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Bone Fix 10X10X10Mm","40008862","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2241.64","2241.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Saw 40Mm","40008863","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit .061","40008864","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","327.27","327.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Cryosur L1150Mm Dia1.7Mm","40008865","CDM","272","RC","C2618","HCPCS","","","facility","both","","","","737.57","737.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.75Mm","40008866","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.5Mm","40008867","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3Mm","40008868","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2.75Mm","40008869","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca  Blln L20Mm Dia2.5Mm","40008870","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca  Blln L20Mm Dia2.5Mm","40008871","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2Mm","40008872","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia1.5Mm","40008873","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia1.5Mm","40008874","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia1.2Mm","40008875","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia1.2Mm","40008876","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia4Mm","40008877","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia3.75Mm","40008878","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia3.5Mm","40008879","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia3.25Mm","40008880","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia3Mm","40008881","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2.75Mm","40008882","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2.5Mm","40008883","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2.25Mm","40008884","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2Mm","40008885","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia1.5Mm","40008886","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia1.2Mm","40008887","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia4Mm","40008888","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia3.75Mm","40008889","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia3.5Mm","40008890","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia3.25Mm","40008891","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia3Mm","40008892","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia2.75Mm","40008893","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia2.5Mm","40008894","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia2.25Mm","40008895","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia2Mm","40008896","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia1.5Mm","40008897","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia1.5Mm","40008898","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia1.2Mm","40008899","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia1.2Mm","40008900","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia4Mm","40008901","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia3.75Mm","40008902","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia3.5Mm","40008903","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia3.25Mm","40008904","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia3Mm","40008905","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia2.75Mm","40008906","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia2.5Mm","40008907","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia2.25Mm","40008908","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia2Mm","40008909","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia1.5Mm","40008910","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia1.5Mm","40008911","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia1.2Mm","40008912","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia6Mm","40008913","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia5.5Mm","40008914","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Xl-W11.81Xh0.6Xl23.62In Vac","40008915","CDM","272","RC","A6550","HCPCS","","","facility","both","","","","221.84","221.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 4 Thk12Mm Knee","40008916","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cable Sur 2Mm Vit For Dall-M","40008917","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","586.49","586.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cbl Sl Sm Dia2Mm Vit Bead","40008918","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","715.83","715.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz E Dia52Mm 11 H","40008919","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4306.22","4306.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icast Cvr Stnt 8Mmx38Mmx120Cm","40008920","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4338.19","4338.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Prost Hydrgel Rad Ther","40008921","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4587","4587","","","","","","","","","","","","","Gross Charge Type: Standard"
"Asahi Crosslead .035 Coil Len","40008922","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-7 13Mm L Fix Bear Ucong","40008923","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.25Mm","40008924","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia5Mm","40008925","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L6Mm Dia2.5Mm","40008926","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia7Mm","40008927","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L120Mm Dia6Mm","40008928","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L45Mm Dia3.5Mm","40008929","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia3Mm","40008930","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia2.5Mm","40008931","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia2Mm","40008932","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia6Mm","40008933","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia5Mm","40008934","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia4Mm","40008935","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1085.5","1085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia4Mm","40008936","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia6Mm","40008937","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1277.55","1277.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L10Mm Dia2.5Mm","40008938","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca  Blln L10Mm Dia3Mm","40008939","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L30Mm Dia10Mm","40008940","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4795.5","4795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L60Mm Dia3.5Mm","40008941","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4795.5","4795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L60Mm Dia5Mm","40008942","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","4795.5","4795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L30Mm Dia5.5Mm","40008943","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5.5Mmx60Mmx6Fr Shockwave","40008944","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 8Mm X 80Mm Blln 5Fr Shth","40008945","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 4.0Mmx25Mm Blln 2.02.9Fr","40008946","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","195.3","195.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 3.5Mmx25Mm Blln 2.02.7Fr","40008947","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.25Mm X 30Mm Biotronik","40008948","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil Blln L30Mm Dia2.5Mm","40008949","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.00Mm X 20Mm Blln 2.0Fr","40008950","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 1.5Mm X 20Mm Blln 200Cm","40008951","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 5.5Mm X 40Mm Blln 150Cm","40008952","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.5Mm X 40Mm Blln 150Cm","40008953","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L12Mm Dia3.5Mm","40008954","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Cm Dia6Mm","40008955","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho L60Mm Dia6.5Mm","40008956","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia9Mm","40008957","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L40Mm Dia4Mm","40008958","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia5Mm","40008959","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","385.79","385.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia1.5Mm","40008960","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L120Mm Dia5Mm","40008961","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L300Mm Od2Mm","40008962","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art L110Cm L60Mm Dia5Mm","40008963","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Litho Blln L40Mm Dia3.5Mm","40008964","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art L110Cm L60Mm Dia6Mm","40008965","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3822.5","3822.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blln Ptca Cut Cor 2.5Mm Blde","40008966","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vlvulplsty L4.5Cm Dia26Mm","40008967","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vlvlplsty L4.5Cm Dia25Mm","40008968","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vlvulplsty L4.5Cm Dia24Mm","40008969","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vlvulplsty L4Cm Dia16Mm","40008970","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1319.3","1319.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia6Mm","40008971","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","385.79","385.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L6Cm Dia8Mm","40008972","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L6Mm Blln Dia2.75Mm","40008973","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L10Mm Blln Dia2.25Mm","40008974","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L10Mm Dia2Mm","40008975","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln 5.0Mmx15Mmx145Cm","40008976","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"4Mm X 4Cm Balloon 4Fr Sheath","40008977","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia18Mm","40008978","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","139.5","139.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia16Mm","40008979","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"10 Mm X 2 Cm Balloon 5.8 Fr X","40008980","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","624.4","624.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia9Mm","40008981","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"9 Mm X 3 Cm Balloon  75 Cm Le","40008982","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"9 Mm X 2 Cm Balloon  75 Cm Le","40008983","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 8X40Mm 75Cm","40008984","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"8 Mm X 3 Cm 75 Cm Length Ul","40008985","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia8Mm","40008986","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm Od5.3Fr Blln","40008987","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia7Mm","40008988","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"6 Mm X 8 Cm 90 Cm Length Ul","40008989","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"6Mm X 4Cm 90 Cm Length Ultr","40008990","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"6 Mm X 2 Cm Balloon 5.3 Fr X","40008991","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L90Cm Od5.3Fr Blln","40008992","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"5 Mm X 4 Cm Balloon 5.3 Fr X","40008993","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"5 Mm X 2 Cm Balloon 5.3 Fr X","40008994","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"4 Mm X 8 Cm Balloon 5.3 Fr X","40008995","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"4 Mm X 4 Cm Balloon  5.3 Fr X","40008996","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"4 Mm X 2 Cm Balloon  5.3 Fr X","40008997","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia4Mm","40008998","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 8X40Mm 75Cm","40008999","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 7X40Mm 75Cm","40009000","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 6X40Mm 75Cm","40009001","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5Mm X 4Cm X 150Cm Symmetry S","40009002","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"3Mm X 10Cm X 150Cm Symmetry St","40009003","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia3Mm","40009004","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3Mm X 2Cm X 150Cm Symmetry Sti","40009005","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.5Mm X 10Cm X 150Cm Symmetry","40009006","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia2.5Mm","40009007","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.5Mm X 2Cm X 150Cm Symmetry S","40009008","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2Mm X 10Cm X 150Cm Symmetry St","40009009","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2Mm X 4Cm X 150Cm Symmetry Sti","40009010","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2Mm X 2Cm X 150Cm Symmetry Sti","40009011","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2Mm X 4Cm X 90Cm Symmetry Stif","40009012","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia2.5Mm","40009013","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2.5Mm","40009014","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2X20Mm 90Cm","40009015","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil Blln L40Mm Dia3.5Mm","40009016","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.5Mm","40009017","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3Mm","40009018","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2.5Mm","40009019","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia7Mm","40009020","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia5Mm","40009021","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"5Mm X 20Mm Balloon 135Cm Shaf","40009022","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia4Mm","40009023","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia4Mm","40009024","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia3Mm","40009025","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"6.0 Mm X 40 Mm Balloon 120 Cm","40009026","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca  Blln L20Mm Dia3Mm","40009027","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"6Mm X 100Mm Balloon 120Cm Pol","40009028","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1118.9","1118.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.0 Mm X 80 Mm Balloon 120 Cm","40009029","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1118.9","1118.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.0 Mm X 40 Mm Balloon 120 Cm","40009030","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1118.9","1118.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"5Mm X 100Mm Balloon 120Cm Pol","40009031","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1118.9","1118.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.0 Mm X 40 Mm Balloon 120 Cm","40009032","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1299.26","1299.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia3Mm","40009033","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1299.26","1299.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2.5Mm","40009034","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia6Mm","40009035","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia8Mm","40009036","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia5Mm","40009037","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X15Mm Mrail","40009038","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X8Mm Mrail","40009039","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X15Mm Otw","40009040","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X12Mm Otw","40009041","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 4X20Mm Mrail","40009042","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.75X20Mm Mrail","40009043","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","422.51","422.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.5X20Mm Mrail","40009044","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.25X20Mm Mrail","40009045","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3X20Mm Mrail","40009046","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.5X20Mm Mrail","40009047","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.25Mm Dia X 20Mm Apex Monorai","40009048","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2X20Mm Mrail","40009049","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","484.3","484.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X20Mm Mrail","40009050","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 4X15Mm Mrail","40009051","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","332.33","332.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.75Mm Dia X 15Mm Apex Monorai","40009052","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.5X15Mm Mrail","40009053","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.25Mm Dia X 15Mm Apex Monorai","40009054","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3X15Mm Mrail","40009055","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.75Mm Dia X 15Mm Apex Monorai","40009056","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L15Mm Dia2.5Mm","40009057","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","325.65","325.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.50Mm Dia X 12Mm Apex Monorai","40009058","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"4.00Mm Dia X 12Mm Apex Monorai","40009059","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.75Mm Dia X 12Mm Apex Monorai","40009060","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.5X12Mm Mrail","40009061","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.25Mm Dia X 12Mm Apex Monorai","40009062","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia3Mm","40009063","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.75X12Mm Mrail","40009064","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L12Mm Dia2.5Mm","40009065","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.25X12Mm Mrail","40009066","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X12Mm Mrail","40009067","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 4X8Mm Mrail","40009068","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.50Mm Dia X 8Mm Apex Monorail","40009069","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.75Mm Dia X 8Mm Apex Monorail","40009070","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3.25X8Mm Mrail","40009071","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3X8Mm Mrail","40009072","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.5X8Mm Mrail","40009073","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.25X8Mm Mrail","40009074","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2X8Mm Mrail","40009075","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X8Mm","40009076","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.5X15Mm Otw","40009078","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.5X12Mm Otw","40009079","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.25Mm Dia X 12Mm Apex Otw Ptc","40009080","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2X12Mm Otw","40009081","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 3X8Mm Otw","40009082","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2.5X8Mm Otw","40009083","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.25Mm Dia X 8Mm Apex Otw Ptca","40009084","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 2X8Mm Otw","40009085","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 1.5X8Mm Otw","40009086","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.75Mm X 30Mm Nc Quantum Apex","40009087","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv Dia4Mm Tomcat Red Hb","40009088","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","103.23","103.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L40Mm Dia4Mm Cort","40009089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","86.04","86.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"H16Mm R Vivacit-E Polyeth Med","40009090","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 6 R Nar Cr Persona","40009091","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3502.8","3502.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 H10Mm R Vivacit-E Med Cong","40009092","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Insuf L120Mm Ult Veres","40009093","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","161.6","161.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cvr Blln Exp 8Mm X 59Mm X 80Cm","40009094","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4165.83","4165.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Galaflex Scfld 15X20Cm","40009095","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","5490.5","5490.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.5Mm X 26Mm Orsiro","40009096","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1395","1395","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.25Mm X 15Mm Orsiro","40009097","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X54Mm Canclls Cann","40009098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","381.33","381.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Inter L24Mm Dia3Mm Plla","40009099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Inter L22Mm Dia3Mm Plla","40009100","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Inter L20Mm Dia2.7Mm Plla","40009101","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L42Mm Dia3.5Mm Lng","40009102","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia3.5Mm Thrd","40009103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Tightrope Ii Rt","40009104","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1036.95","1036.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Clav 8 H St 102Mm","40009105","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1495.3","1495.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Fix L229Mm Dia2Mm Ss Styl","40009106","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","35.07","35.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card Co Xt Hf Mri Is1","40009107","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","33360","33360","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 10Mm 1 Lev","40009108","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.65","1074.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys 6F 135Cm Cath Len 6Mm Impl","40009109","CDM","278","RC","C1877","HCPCS","","","facility","both","","","","3475","3475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X30Mm Canc Hex Drv","40009110","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2X16Mm Mand Cort Ft","40009111","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1282.98","1282.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X8Mm Cort Ft Ss","40009112","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","218.63","218.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann 7.3Mm X 30Mm W/16Mm","40009113","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X48Mm Mtphseal E","40009114","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.55","113.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X80Mm Canc Hex","40009115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X85Mm Canc Hex","40009116","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Cran 4 H X Ti Ult Lp","40009117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","625.49","625.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cor L135Cm Telscp L150Mm","40009118","CDM","272","RC","C1753","HCPCS","","","facility","both","","","","1753.5","1753.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Introducer 8Fr L63Cm","40009119","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","366.39","366.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rotawire Drv Floppy 5 Pk","40009120","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","2224.82","2224.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L150Cm Dia0.035In 3Cm","40009121","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","598.29","598.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Onyxng22508Ux Onyx","40009122","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L150Mm Dia4.0Mm","40009123","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L150Mm Dia5.0Mm","40009124","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L120Cm D2.33Mm 2.4-3.4Mm","40009125","CDM","272","RC","C1724","HCPCS","","","facility","both","","","","7440.67","7440.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Crv 6Fr L120Cm 2-5-2Mm Sp","40009126","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","307.29","307.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep 5Fr L110Cm 5Mm Spc 4","40009127","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","280.98","280.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep F Crv 6Fr L115Cm 1Mm","40009128","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","280.98","280.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inthrill Sheath","40009129","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","3006","3006","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inthrill Catheter","40009130","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","3058","3058","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pacemaker Crd 31Gm 6.5X53X53Mm","40009131","CDM","272","RC","C2621","HCPCS","","","facility","both","","","","7645","7645","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm Dia2.75Mm Cath","40009132","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"L135Cm Tip L5.9Cm Ves Dia3-7Mm","40009133","CDM","272","RC","C1714","HCPCS","","","facility","both","","","","4649.55","4649.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng40038Ux Onyx 4.00X38Rx","40009134","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 3.5Mm X 13Mm Orsiro","40009135","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia8Mm","40009136","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L60Mm Dia8Mm","40009137","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L80Mm Dia8Mm","40009138","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia9Mm","40009139","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guiding 6Fr L119Cm R2P","40009141","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","672.9","672.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Qplr Fix A Cruve Auto","40009142","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","117.18","117.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Qplr Fix F Cruve Auto","40009143","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","117.18","117.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng50022Ux Onyx 5.00X22Rx","40009144","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Map 8Fr X 113Cm D-F Crv","40009145","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","3547.28","3547.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng20008Ux Onyx 2.00X08Rx","40009146","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.75Mm X 13Mm Orsiro","40009147","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng35022Ux Onyx 3.50X22Rx","40009148","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth 6Fr L10Cm L2.5Cm 0.038In","40009149","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","706.02","706.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L300Cm Dia0.014In Coil","40009150","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth Guidng 6Fr L149Cm Str R2P","40009151","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","672.9","672.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L80Mm Dia4.0Mm","40009152","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eluvia Us 7X150 130 Cm","40009153","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6394","6394","","","","","","","","","","","","","Gross Charge Type: Standard"
"Had Cath 15.5Fr X 55Cm Crv Cuf","40009154","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","914.3","914.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microcath L135Cm Od2.9X2.1Fr","40009155","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1419.5","1419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng30026Ux Onyx 3.00X26Rx","40009156","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng40026Ux Onyx 4.00X26Rx","40009157","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia4.0Mm","40009158","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L60Mm Dia4.0Mm","40009159","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia5.0Mm","40009160","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L150Mm Dia6.0Mm","40009161","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyxng35026Ux Onyx 3.50X26Rx","40009162","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Thromctmy Cath 115Cm Htorq","40009163","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","13580.3","13580.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"My Sys 2.75Mm X 18Mm Orsiro","40009164","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm Blln 5X150Mm","40009165","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2914.15","2914.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm Blln 6X150Mm","40009166","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2914.15","2914.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm Blln 6X100Mm","40009167","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2688.7","2688.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X36Mm Compr Hdls","40009168","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X50Mm Compr Hdls","40009169","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X48Mm Compr Hdls","40009170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.02","1079.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5Mm Compr Ft Hd","40009171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","568.2","568.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Artc C-D Fem 4-5 13Mm","40009172","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sentiva Generator","40009173","CDM","278","RC","C1767","HCPCS","","","facility","both","","","","54411.55","54411.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Optmzr Smart Mini Implntbl Gen","40009174","CDM","278","RC","C1824","HCPCS","","","facility","both","","","","36140","36140","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5/4.0 Lat Top Load Rod Conn","40009175","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1795.25","1795.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tibial Nail 9 Mm Len 300 Mm","40009176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2620.83","2620.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Mt L Ti Ortholoc 3Di","40009177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Strnl Manubrium 12 H","40009178","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2109.79","2109.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Strnl Manubrium 14 H","40009179","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1561.95","1561.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Strnm 12 H Str Lok","40009180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2248.59","2248.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Strnl 10 H Wide X","40009181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1376.92","1376.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3Mm X 14Mm Strnm Lok","40009182","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","418.28","418.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3Mm X 16Mm Strnm Lok","40009183","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","418.28","418.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X38Mm Hex Drv","40009184","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.54","364.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X22Mm Compr Hdlss","40009185","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X28Mm Compr Hdlss","40009186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disc W13Xh5Xl17Mm Cerv Cocr","40009187","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","7506","7506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix Hld Swvlg","40009188","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","847.54","847.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Fix L100Mm Dia1.25Mm Ss","40009189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","739.56","739.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L100Mm Dia1.6Mm Ss","40009190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","739.56","739.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix Dia3Mm Ss Ang Conn","40009191","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","10.43","10.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Lag Cort","40009192","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.37","965.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcompr Cath 8.5Fr 350Cm Colon","40009193","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","341.19","341.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monarch Bronchoscope System","40009194","CDM","272","RC","C1601","HCPCS","","","facility","both","","","","6943.05","6943.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.3Mm X 7Mm Thor","40009195","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","858.31","858.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Rib 20 H St X Thck","40009196","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2087.63","2087.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver Sur Blde 80Mm","40009197","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","381.44","381.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Centerpiece Spnl 35-51Mm 13Mm","40009198","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","14450.44","14450.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Str Ln 5.5Mmx500Mm","40009199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Stretch Gore Tex  703100","40009200","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1033.73","1033.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L40Cm Dia4-7Mm Tapr","40009201","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","963.59","963.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia10Mm Std","40009202","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1067.92","1067.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia16Mm Cllgn","40009203","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","956.71","956.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia18Mm Cllgn","40009204","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1105.97","1105.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia20Mm Poly","40009205","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","956.71","956.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia26Mm Thor","40009206","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","962","962","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia28Mm Thor","40009207","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","962","962","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia30Mm Thor","40009208","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","962","962","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia32Mm Thor","40009209","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","962","962","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L40Cm Id6Mm Eptfe","40009210","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1491.31","1491.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Ventral Hern 6Inx8In","40009211","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","10174.74","10174.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 H10Mm R Vivacit-E Med","40009212","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Ant Cerv 32Mm Std","40009213","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1419.5","1419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 11.5X75Mm","40009214","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4865","4865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 10X75Mm Ti","40009215","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4865","4865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X56Mm Compr Hdlss","40009216","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Otlif W9Xh14Xl26Mm","40009217","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal 6Mm X 80Mm Post Crv","40009218","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Hld For 1.6Mm K Wire","40009219","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","847.54","847.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix Xsm Dia3Mm 1 H C","40009220","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1051.65","1051.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hndl Scrdrvr Dia0.6/1.6Mm Cann","40009221","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1208.6","1208.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X32Mm Hex Drv","40009222","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.54","364.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Hex Drv","40009223","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.54","364.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X44Mm Hex Drv","40009224","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.54","364.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L52Mm Dia2.7Mm Ti","40009225","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","271.66","271.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnal Cerv W17Xh8Mm D14Mm","40009226","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spinal L W17Xh7Mm Dia14Mm","40009227","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl 20 Deg 8Mmx10Mmx25Mm","40009228","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl 20 Deg 7Mmx10Mmx25Mm","40009229","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X110Mm Cancell","40009230","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","83.7","83.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Blln L4Cm 18Fr 10Ml","40009231","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","597.64","597.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Cage Ex Lg W18 H05 7","40009232","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal Cerv 39Mm 3 Lev","40009233","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal L75Mm Dia5.5Mm Post","40009234","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.93","496.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Fav Ang 9.0Mmx60Mm","40009235","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3198.83","3198.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnal Fav Ang 9.0Mmx60Mm","40009236","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3189.83","3189.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L12In Dia1.2Mm Nit","40009237","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","111.6","111.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub Ptty Xsm 2Cc","40009238","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Shv 5.5Mmx125Mm Std","40009239","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","103.23","103.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Hydrcoll W4Xl4In Bge Sq","40009240","CDM","623","RC","A6234","HCPCS","","","facility","both","","","","4.32","4.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filter Smk Evac Ulpa Plume Grd","40009241","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","858.55","858.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urin Cath 16Fr Tbng L60In 5Cc","40009242","CDM","272","RC","A4315","HCPCS","","","facility","both","","","","58.45","58.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ureth 12Fr L16In 5Cc Blln","40009243","CDM","272","RC","A4344","HCPCS","","","facility","both","","","","47.4","47.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Litho 12Fr L3.76Mm Disp","40009244","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1157.31","1157.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hip 3H St 62Mm","40009245","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.43","1022.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hip 2H St 46Mm","40009246","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.43","1022.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X105Mm Canc Hex","40009247","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 55Mm W/32Mm T","40009248","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz F Dia58Mm 13 H","40009249","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4306.22","4306.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5.5X80Mm Stardrv","40009250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L12Mm Dia3Mm Strnl","40009251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","418.29","418.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar 31Mmx26Mmx10Cm 20Fr","40009252","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","30388.18","30388.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 645Cc Dia14.9Cm","40009253","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 750Cc Dia13.7Mm","40009254","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Manubrium Strnm L 8","40009255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1316.03","1316.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 50Mm W/32Mm T","40009256","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X130Mm Canc Hex","40009257","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X125Mm Canc Hex","40009258","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X120Mm Canc Hex","40009259","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X115Mm Canc Hex","40009260","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X110Mm Canc Hex","40009261","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X105Mm Canc Hex","40009262","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X100Mm Canc Hex","40009263","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X90Mm Canc Hex","40009264","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X85Mm Canc Hex","40009265","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X80Mm Canc Hex","40009266","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X75Mm Canc Hex","40009267","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X70Mm Canc Hex","40009268","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 65Mm Full Thr","40009269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 60Mm Full Thr","40009270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 40Mm Full Thr","40009271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 35Mm Full Thr","40009272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 30Mm Full Thr","40009273","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 4H St 78Mm 135Deg","40009274","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1022.43","1022.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ef H13Mm L Knee Vivacit-E","40009275","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 25Mm Full Thr","40009276","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 20Mm Full Thr","40009277","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 130Mm W/16Mm","40009278","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X125Mm Canc Hex","40009279","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X65Mm Canc Hex","40009280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X55Mm Canc Hex","40009281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X45Mm Canc Hex","40009282","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 7.3Mm X 35Mm W/16Mm T","40009283","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia4Mm 18Atm","40009284","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia4Mm 18Atm","40009285","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","100.44","100.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia4Mm 18Atm","40009286","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia4Mm 18Atm","40009287","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L20Mm Dia4Mm 18Atm","40009288","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnsf 12Mm Disp Oats 2.0","40009289","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L4In Dia2Mm Fast Guide","40009290","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","218.54","218.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 H10Mm L Med Cong Fix Bear","40009291","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X55Mm","40009292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6255","6255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X55Mm","40009293","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6255","6255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod C/Peek Crv 6.0 R450X120Mm","40009294","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4795.5","4795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod C/Peek Crv 6.0 R450X140Mm","40009295","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4795.5","4795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X42Mm Compr Hdlss","40009296","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1085.68","1085.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth 2Mm X 150Mm Nthrd","40009297","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","170.93","170.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia2.7Mm Cann Add On","40009298","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","725.2","725.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Countersink Sur Dia5Mm Cann","40009299","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","762.66","762.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L65Mm Dia7Mm Hdlss","40009300","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1918.33","1918.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L80Mm Dia7Mm St Cann","40009301","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1918.33","1918.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X46Mm Stardrv","40009302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X70Mm Compr Hdlss","40009303","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.02","1079.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X46Mm Compr Hdlss","40009304","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealer Lap Div L37Mm Dia5Mm L","40009305","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1009.52","1009.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L20Mm Dia7Mm Knee","40009306","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Fix L40Mm Dia4.5Mm Bicort","40009307","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L42.5Mm Od4.5Mm Ti","40009308","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L320Mm Dia10Mm Dst","40009309","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2893.37","2893.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Uro 10/12Fr L46Cm Dil","40009310","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","297.77","297.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L40Mm Dia6.5Mm Canc","40009311","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","198.47","198.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Cmf 150-200Cm Squared","40009312","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","36772.45","36772.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X52Mm Canc Hex Drv","40009313","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","381.33","381.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Rmr 16Mm For Ria 2 Bne","40009314","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1094.69","1094.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscope 2.8Mm Ultraslim","40009315","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","802.8","802.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L90Mm Std 3 H Prox","40009316","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2285.7","2285.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 H10Mm R Vivacit-E Med Cong","40009317","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Fem Sz 5 L Nar Cr Persona","40009318","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3502.8","3502.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.5X40Mm Polyax Fen Cann Xtab","40009319","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"6.5X35Mm Polyax Fen Cann Xtab","40009320","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 13X100Mm Lag Canc","40009321","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","645.38","645.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L40Mm Dia7.5Mm Cort","40009322","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1403.53","1403.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl 20Deg 9Mmx10Mmx25Mm","40009323","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 3.5Mm W/ Sz 2 L36In","40009324","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1200.73","1200.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hip 4 H 78Mm 135Deg","40009325","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","984.39","984.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss L Med Fem Knee","40009326","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","17097","17097","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L25Mm Dia3Mm C Fbr","40009327","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","80.35","80.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L45Mm Dia3Mm C Fbr","40009328","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","80.35","80.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix Xsm L60Mm Dia3Mm C","40009329","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","80.35","80.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L75Mm Dia3Mm C Fbr","40009330","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","80.35","80.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Fem Rg Dia10Mm L300Mm","40009331","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3131.45","3131.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Rmr Dia9Mm Flx","40009332","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","697.54","697.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Rmr Dia9.5Mm Flx","40009333","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","697.54","697.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shaft Rmr Flx For Valor","40009334","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1516.36","1516.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im M 10Mm X 200Mm R Ti","40009335","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","5483.27","5483.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X65Mm Star 25 Drv","40009336","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","834.91","834.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ef H12Mm L Knee Vivacit-E","40009337","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X155Mm Canc Hex","40009338","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X115Mm Canc Hex","40009339","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X65Mm Canc Hex","40009340","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 2 Thk11Mm Knee","40009341","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Sz 29 Thk9Mm Sup","40009342","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 1 R Knee Cr","40009343","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 2 L Knee","40009344","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.75Mmx16Mm  Synergy Xd","40009345","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl 20Deg 11Mmx10Mmx30Mm","40009346","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X55Mm Post Thorc","40009347","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","956.94","956.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa Cvr 20Mmx13.5Cm","40009348","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7786.78","7786.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Gi Tiss Ctrl 18Mm Assurnc","40009349","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Had Cath 13Fr Insrt L15Cm Str","40009350","CDM","278","RC","C1752","HCPCS","","","facility","both","","","","430.41","430.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Had Ad L20Cm Dia13Fr Polyur N","40009351","CDM","278","RC","C1752","HCPCS","","","facility","both","","","","430.41","430.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Had Cath 13Fr X 24Cm Sht Term","40009352","CDM","278","RC","C1752","HCPCS","","","facility","both","","","","430.41","430.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thrmdil 7.5Fr L110Cm 5 Lu","40009353","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","1059.25","1059.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilator Surg Cnl Disp St Milex","40009354","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","20.92","20.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2X28Mm Cort T6 Star","40009355","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","80.91","80.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth 6.5Fr L11Cm Gwire 0.038In","40009356","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","117.74","117.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth 6Fr Wrk Wre 0.038In J Tip","40009357","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","194.01","194.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntnr Drnge 1000Ml Vac Btl Lok","40009358","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","113.73","113.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dia8.5Mm Gwire 0.038In Mac Loc","40009359","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","288","288","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L93Mm 4 H R Med Prox","40009360","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2189.82","2189.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Cmf Sht 2X2 H L 2Mm","40009361","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","460.99","460.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.85X5Mm Cmf Slf Drl","40009362","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","189.78","189.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.85X10Mm Cmf St Ti","40009363","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180.23","180.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.85X14Mm St Ti","40009364","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180.23","180.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L16Mm Dia1.85Mm Ti","40009365","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180.23","180.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 1.4Mm X 125Mm J Latch","40009366","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","533.86","533.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sur Proc 2 Splnt Pt Spec","40009367","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","4983.15","4983.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Pt Spec Splnt Ortho","40009368","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1915.49","1915.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Splnt Pt Spec Ortho","40009369","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1915.49","1915.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"3-11 H12Mm L Vivacit-E Cr Fix","40009370","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L16Mm Dia4Mm 18Atm","40009371","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L100Mm Dia4.0Mm","40009372","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uret Stnt 6Fr L24Cm Met","40009373","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","1625.04","1625.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Diag 1.9Fr L150Cm D0.042","40009374","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide 7Fr L100Cm L Cor Ss","40009375","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Stone 6Fr L23Cm 1.25Ml","40009376","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","303.95","303.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X100Mm Pelv Cort","40009377","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","65.82","65.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L255Mm Dia8.5Mm R Hum","40009378","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2262.43","2262.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5Xl60Mm Star 25 Drv","40009379","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","945.52","945.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X46Mm Mtphseal","40009380","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.55","113.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L2Mm Thk0.8Mm R Max","40009381","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","764.35","764.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L2Mm Thk0.8Mm L Max","40009382","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","764.35","764.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X22Mm","40009383","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Crv Ln Ti 6Mmx500Mm","40009384","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Sft Tiss 9Cm Cir Rein","40009385","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1912.15","1912.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Umb Neo 2.8Fr 22Ga L34Cm","40009386","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","56.8","56.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X24Mm Cort Hex","40009387","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","55.72","55.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X48Mm Canc Cann","40009388","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hip 3 H 62Mm 135Deg","40009389","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","942.04","942.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 13X90Mm Canc Cann","40009390","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","599.62","599.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Hum Ft Lok","40009391","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X32Mm Hum Ft Lok","40009392","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L42Mm Dia4Mm Hum","40009393","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","312.2","312.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 6 H Str 78Mm Ss Lp","40009394","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","702.52","702.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X75Mm Canc Hex","40009395","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X140Mm Canc Hex","40009396","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X100Mm Canc Hex","40009397","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X60Mm Hex Drv","40009398","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.57","546.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Compr Canc","40009399","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","46.79","46.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X14Mm Fib Cort","40009400","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","233","233","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia4Mm Co Ally","40009401","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L137Cm L6Mm Dia2Mm","40009402","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L137Cm L10Mm Dia3Mm","40009403","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm D3.5Mm","40009404","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm Dia3Mm","40009405","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm D2.75Mm","40009406","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm D2.5Mm","40009407","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm D2.25Mm","40009408","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm Dia2Mm","40009409","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm Dia3.5Mm","40009410","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","289.9","289.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm D3.25Mm","40009411","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm Dia3Mm","40009412","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L137Cm L6Mm D2.75Mm","40009413","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm Dia2.5Mm","40009414","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm D2.25Mm","40009415","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L6Mm Dia2Mm","40009416","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L40Mm Dia3Mm","40009417","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L40Mm D2.5Mm","40009418","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L40Mm Dia2Mm","40009419","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L30Mm Dia2Mm","40009420","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L20Mm Dia2Mm","40009421","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L20Mm D1.5Mm","40009422","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L15Mm D1.5Mm","40009423","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L12Mm D1.5Mm","40009424","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L20Mm D1.2Mm","40009425","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L15Mm D1.2Mm","40009426","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia12Mm","40009427","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","963.36","963.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L20Mm Dia12Mm","40009428","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 8Fr L100Cm D10-46Mm","40009429","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","119.97","119.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln 12X40Mm","40009430","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia10Mm","40009431","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm 6Fr L40Mm D9Mm","40009432","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia7Mm","40009434","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L40Mm Dia5Mm","40009436","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L8Mm Dia2.5Mm","40009437","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","312.2","312.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cor 3X15Mm Otw 143Cm","40009438","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L15Mm D2.5Mm","40009439","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2X15Mm Otw 143Cm","40009440","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 3X12Mm Otw 143Cm","40009441","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L12Mm D2.5Mm","40009442","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","477.22","477.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia6Mm","40009443","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia8Mm","40009444","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia6Mm","40009445","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L40Mm Dia5Mm","40009446","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.75Mm X 35Mm Orsiro","40009447","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X34Mm Compr Hdlss","40009448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1085.68","1085.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Countersink Drl Dia4Mm Cann","40009449","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Orth L800Mm Dia2.5Mm Ss","40009450","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","325.47","325.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"High Angltn Plate 3-Level 45Mm","40009451","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 4.0 Len 16Mm Self-Drill","40009452","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 4.0 Len 18Mm Self-Drill","40009453","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Tmp Fix Union Max","40009454","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"H12Mm L Vivacit-E Polyeth Med","40009455","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Sur L8.6In Dia12.5Mm","40009456","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","708.11","708.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X4 H T Plt 57Mm R","40009457","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","666.15","666.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Prox R 4 H St Lo","40009458","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2195","2195","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Bio W 6Xl10Cm Ovine Rumen","40009459","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","951.9","951.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Sur Sft Tiss 12Cm X 18Cm","40009460","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4245.06","4245.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ti-Life Ant Crv Cage W18 H06 7","40009461","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X46Mm Compr Hdlss","40009462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","851.03","851.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X55Mm Compr Hdlss","40009463","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","851.03","851.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X60Mm Compr Hdlss","40009464","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","851.03","851.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Dia3.5Mm Cann Add On","40009465","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","725.2","725.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X38Mm Compr Hdlss","40009466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X44Mm Compr Hdlss","40009467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","855.14","855.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L32Mm Dia4Mm Smth Shk","40009468","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L75Mm Dia3.5Mm Ti","40009469","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","617.71","617.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"K Wire Fix L150Mm Dia1.4Mm Ss","40009470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","38.58","38.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer Orth Ns Ti For 4Mm Cann","40009471","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.81","90.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Nail Troch Fix 11.0Mmx70Mm","40009472","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","781.79","781.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L8Mm Dia2.25Mm","40009473","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L135Cm L10Cm Od5.8Fr Odse","40009474","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","139.5","139.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L135Cm L10Cm Od5Fr Odsec5","40009475","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L100Mm Dia4Mm","40009476","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia4Mm","40009477","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","836.25","836.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia4Mm","40009478","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia3Mm","40009479","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L100Mm Dia2.5","40009480","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm D2.5Mm","40009481","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia2Mm","40009482","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L100Mm Dia2Mm","40009483","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L100Mm Dia3Mm","40009484","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L100Mm D2.5Mm","40009485","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L80Mm Dia6Mm","40009486","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia6Mm","40009487","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L20Mm Dia2Mm","40009488","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L120Mm Dia5Mm","40009489","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L12Mm Dia2.25Mm Otw","40009490","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1386.1","1386.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L8Mm Dia2.25Mm Otw","40009491","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L6Mm Dia2.25Mm Otw","40009492","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.7","200.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia5Mm","40009493","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia4Mm","40009494","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","301.05","301.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L137Cm L10Mm D3.5Mm","40009495","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L155Cm L100Mm Od3Mm","40009496","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1920.5","1920.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L137Cm L100Mm Dia3Mm","40009497","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1920.5","1920.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cor 2.75X6Mm Mrail","40009498","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia3Mm","40009499","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia4.5Mm","40009500","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia5Mm","40009501","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2.75Mm","40009502","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L20Mm D3.5Mm","40009503","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1685.03","1685.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L8Mm D5Mm","40009504","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L8Mm D2.75Mm","40009505","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L142Cm L10Mm D2.5Mm","40009506","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","201.37","201.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Periph 5Fr 138Cm 0.014In","40009507","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","1010.35","1010.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 R Knee Cem","40009508","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2672","2672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 5 Thk10Mm Knee","40009509","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Thk10Mm Dia32Mm","40009510","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1002","1002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz 5 Univ Knee","40009511","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X26Mm St Xl25 Rcss","40009512","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Canc Cann","40009513","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X56Mm Tib Cort","40009514","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","52.28","52.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L25Mm Dia10Mm L75Cm L30Mm","40009515","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1985.63","1985.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 6.5Mmx50Mm","40009516","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 6.5Mmx55Mm","40009517","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 150Mm Sz 6 Hi Offset","40009518","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3235.23","3235.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X28Mm St Xl25 Rcss","40009519","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X30Mm St Xl25 Rcss","40009520","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screwdriver T30 Stardrv Shft","40009521","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","883.4","883.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 10 H 101Mm Ss Va-Lcp","40009522","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1430.51","1430.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forceps Sur L7 5In Plt Hld","40009523","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1056.04","1056.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med 40Mm Sm 1 Hnd Appl","40009524","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2270.45","2270.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7X50Mm Compr Hdlss","40009525","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1375.45","1375.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7X60Mm Compr Hdlss","40009526","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1375.45","1375.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autotome Pro Rx 39 25Mm Cut","40009527","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","896.21","896.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromctmy Cath 100Cm Xtorq Tip","40009528","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","13413.5","13413.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fngr Sz7 L68.1Mm Dia9.1Mm","40009529","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3584.81","3584.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Screw 3.50Mm X 14Mm","40009530","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Screw 3.75Mm X 14Mm","40009531","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Lord 3D Ti 14Mmx12Mmx6Mm","40009532","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Lord 3D Ti 14Mmx12Mmx7Mm","40009533","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 5.5Mmx35Mm","40009534","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 5.5Mmx40Mm","40009535","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 5.5Mmx45Mm","40009536","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Mis Perc 5.5Mmx200Mm","40009537","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia4.5Mm Co","40009538","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Card Mon Linq Reveal","40009539","CDM","278","RC","C1764","HCPCS","","","facility","both","","","","7360.05","7360.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia4Mm 18Atm","40009540","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia4Mm 18Atm","40009541","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3.5Mm 18Atm","40009542","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia3.5Mm 18Atm","40009543","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia3.5Mm 18Atm","40009544","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L20Mm Dia3.5Mm 18Atm","40009545","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia3.5Mm 18Atm","40009546","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia3Mm 18Atm","40009547","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia3Mm 18Atm","40009548","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia3Mm 18Atm","40009549","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia2.75Mm 18At","40009550","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia2.75Mm 18At","40009551","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia2.75Mm 18At","40009552","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2.75Mm 18Atm","40009553","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia2.5Mm 18Atm","40009554","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia2.5Mm 18Atm","40009555","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Promus L2 Mm Od2. Mm","40009556","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2.5Mm 18Atm","40009557","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia2.25Mm 18At","40009558","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia2.25Mm 18At","40009559","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L20Mm Dia2.25Mm 18At","40009560","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2.25Mm 18Atm","40009561","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L20Mm Dia2.75Mm 18At","40009562","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L32Mm Dia2.25Mm 18At","40009563","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia2.5Mm 18Atm","40009564","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.75Mm 18At","40009565","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.5Mm 18Atm","40009566","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L16Mm Dia3Mm 18Atm","40009567","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L16Mm Dia2.5Mm 18Atm","40009568","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.25Mm 18At","40009569","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia2.5Mm 18Atm","40009570","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia2.75Mm 18At","40009571","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L16Mm Dia2.75Mm 18At","40009572","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3Mm 18Atm","40009573","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia3Mm 18Atm","40009574","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia3.5Mm 18Atm","40009575","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L16Mm Dia2.25Mm 18At","40009576","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia3Mm 16Atm","40009577","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Drg + Dia2.5Mm L32Mm","40009578","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L17Mm Dia8Mm L135Cm L20Mm","40009579","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L17Mm Dia6Mm L75Cm L20Mm","40009580","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L27Mm Dia8Mm L135Cm L30Mm","40009581","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 6Fr L37Mm Dia7Mm L40Mm","40009582","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L17Mm Dia7Mm L135Cm L20Mm","40009583","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 4.5Mmx30Mm","40009584","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.5Mm X 35Mm Polyax","40009585","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.5Mm X 45Mm Polyax","40009586","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L57Mm Dia10Mm L75Cm L60Mm","40009587","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L37Mm Dia10Mm L75Cm L40Mm","40009588","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L57Mm Dia9Mm L75Cm L60Mm","40009589","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 8X57Mm Cath L75Cm L60Mm","40009590","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L57Mm Dia6Mm L75Cm L60Mm","40009591","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L100Mm D7Mm L75Cm","40009592","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L50Mm Dm6Mm 120Cm","40009593","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1628.25","1628.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 8Fr L100Cm Id0.091In Al1","40009594","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Vasc Guid Cls Crv 3.5 Cor","40009595","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","356.8","356.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L100Mm Dia7Mm Cath L120Cm","40009596","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt L80Mm Dia7Mm 6Fr L120Cm","40009597","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L60Mm D7Mm L120Cm","40009598","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm D7Mm L120Cm","40009599","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L120Mm D6Mm L120Cm","40009600","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L100Mm D6Mm L120Cm","40009601","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L80Mm D6Mm L120Cm","40009602","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L60Mm D6Mm L120Cm","40009603","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm D6Mm L120Cm","40009604","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cor Stnt Fulcrum L26Mm Od2.5Mm","40009605","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1065.99","1065.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.5Mm Cocr","40009606","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor Bare Mtl Dia5Mm L24Mm","40009607","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor Bare Mtl 5Mmx20Mm","40009608","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor Bare Mtl 5Mmx16Mm","40009609","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor Bare Mtl Dia5Mm L12Mm","40009610","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia4Mm Radpq","40009611","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L34Mm Dia4Mm Radpq","40009612","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia4Mm Radpq","40009613","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia4Mm Radpq","40009614","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia4Mm Radpq","40009615","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia4Mm Radpq","40009616","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia4Mm Radpq","40009617","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia4Mm Radpq","40009618","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3.5Mm Radpq","40009619","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L34Mm Dia3.5Mm Radpq","40009620","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia3.5Mm Radpq","40009621","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia3.5Mm Radpq","40009622","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3Mm Radpq","40009623","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L34Mm Dia3Mm Radpq","40009624","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2474.94","2474.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia3Mm Radpq","40009625","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia3Mm Radpq","40009626","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2.75Mm","40009627","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia2.75Mm Co","40009628","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia2.75Mm Co","40009629","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia2.75Mm Co","40009630","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L14Mm Dia2.75Mm Co","40009631","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.75Mm Co","40009632","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2.75Mm","40009633","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia2.5Mm Radpq","40009634","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia2.5Mm Radpq","40009635","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L30Mm Dia2.25Mm Radpq","40009636","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L26Mm Dia2.25Mm Radpq","40009637","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L22Mm Dia2.25Mm Radpq","40009638","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L18Mm Dia2.25Mm Radpq","40009639","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L14Mm Dia2.25Mm Radpq","40009640","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Cor L12Mm Dia2.25Mm Radpq","40009641","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Fulcrum L14Mm Od2.25Mm","40009642","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Int Od8Fr Id.091In Sdhl","40009643","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Rt 3.5Crv Od8Fr Id.091I","40009644","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Rt 3.5Crv L100Cm Od8Fr","40009645","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Left 4Crv Od8Fr Id.091In","40009646","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr L100Cm Id0.091In","40009647","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Lft 3.5Crv Od8Fr Id.091In","40009648","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Lft 3.5Crv Od8Fr Id.091In","40009649","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 4Crv Od8Fr Id.091In","40009650","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.5Crv Od8Fr Id.091In","40009651","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.5Crv Od8Fr Id.091In","40009652","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Left 2Crv Od8Fr Id.091In","40009653","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr L100Cm Id0.091In","40009654","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid Mach1 Od8Fr Id.091In","40009655","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr L100Cm Id0.091In","40009656","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Left 1 Crv Od8Fr Id.091In","40009657","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Lft .75Crv Od8Fr Id.091In","40009658","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Lft .75Crv Od8Fr Id.091In","40009659","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"8 Fr X 90Cm Jr 4.0 Sh Gdcath","40009660","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Crv L Lumn H L90Cm Od8Fr","40009661","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Crv L100Cm Od5Fr Id.058In","40009662","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","201.37","201.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cross Conn Spnl Var 28-38Mm","40009663","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","1111.12","1111.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Cerv Ti 4.0Mm X 35Mm","40009664","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","556.56","556.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fem 107Mm Sz 6 Hi Offset","40009665","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3475","3475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med 45Mm Sm 1 Hnd Appl","40009666","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Cryoablation 8Mm X 11In","40009667","CDM","272","RC","C2618","HCPCS","","","facility","both","","","","3614","3614","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Biocryl Rapide","40009668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1207.41","1207.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Fiberstitch Two Ply","40009669","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acet Id38Mm Sz D Mdm","40009670","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2338","2338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Od38Mm Id22.2Mm","40009671","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm L120Mm Dia5.0Mm","40009672","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2997.65","2997.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc 0.014Inx190Cm Str","40009673","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L190Cm Dia0.014In","40009674","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1043.75","1043.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mt Sys 2.75Mm X 30Mm Orsiro","40009675","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep Cs D-F Cruve Defl 12 P","40009676","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","588.05","588.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 9Fr L130Cm L40Mm Dia12Mm","40009677","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7Fr L130Cm L80Mm Dia9Mm","40009678","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7Fr L130Cm L60Mm Dia9Mm","40009679","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 7Fr L100Cm Id0.081In","40009680","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr Id0.091In Tip","40009681","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"4-11 Tib Sz Ef H16Mm R Polyeth","40009682","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1143.95","1143.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 Std L Knee","40009683","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","10854.51","10854.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tib Xsm Tm Cntrl Cone","40009684","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","7294.72","7294.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"H10Mm L Ps Vivacit-E Polyeth","40009685","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2173.51","2173.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Sys 4.00Mm Dia X 34Mm","40009686","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blln Cath 4Mm X 250Mm 130Cm","40009687","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3216.42","3216.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4Mm X 200Mm Blln 130Cm","40009688","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3216.42","3216.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Mm X 39Mm Stent 135Cm","40009689","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.5Mm X 24Mm  Synergy Xd","40009690","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 2.75Mm X 20Mm  Synergy X","40009691","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.0Mm X 8Mm  Synergy Xd","40009692","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 8Frx90Cm Mach 1 Guide Al2","40009693","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 4.00Mm X 26Mm 5Fr X140Cm","40009694","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 3.00Mm X 26Mm 5Fr X140Cm","40009695","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 3.00Mm X 22Mm 5Fr X140Cm","40009696","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.50Mm X 20Mm 5Fr X140Cm","40009697","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X18Mm Canc Hex Hd","40009698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X26Mm Canc Hex Hd","40009699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 13X105Mm Lag Canc","40009700","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","599.62","599.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X54Mm Cort Hex","40009701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","41.79","41.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shnt Vent Ninvas Axiem Tech","40009702","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1077.15","1077.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.25Mm X 20Mm 5Fr X140Cm","40009703","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.75Mm X 15Mm 5Fr X140Cm","40009704","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.50Mm X 15Mm 5Fr X140Cm","40009705","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 4.00Mm X 9Mm 5Fr X 140Cm","40009706","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 7Mm X 80Mm 135Cm Cath","40009707","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1002","1002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 5Mm X 80Mm 135Cm Cath","40009708","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1002","1002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.5Mm X 80Mm 6Fr X 120Cm","40009709","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Aspir 16Fr L15Cm","40009710","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Emb 16Fr L107Cm Triever16","40009711","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Emb 20Fr L90Cm Triever20","40009712","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thromctmy Md 12Fr 120Cm","40009713","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thromctmy Xl 19-25Mm","40009714","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patch Sft Tiss W15X20Cm Thk1Mm","40009715","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1771.87","1771.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc L30Cm Dia14Mm Ptfe","40009716","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","1073.75","1073.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia2Mm Co Plat","40009717","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia4Mm 16Atm Pl","40009718","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Od4.5Mm Co","40009719","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Cryoablation 90Deg Ang","40009720","CDM","272","RC","C2618","HCPCS","","","facility","both","","","","2922.5","2922.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L100Cm Shth Od5Fr Tip","40009721","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L65Cm Od4Fr Gwire Od0.035","40009722","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L38Mm Dia3Mm Del","40009723","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1386.1","1386.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Can 3.0 Mm X 20 Mm Sht Thr","40009724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","368.15","368.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X52Mm Cort Ft","40009725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.87","229.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R 16 H J-Plt 208Mm","40009726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1146.12","1146.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L 14 H J-Plt 182Mm","40009727","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1083.51","1083.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 8X5 H 68.5Mm Ss Lcp Dst","40009728","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.23","1241.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 8X5 H 68.5Mm Ss Lcp Dst","40009729","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.23","1241.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 8X4 H 59.5Mm Ss Lcp Dst","40009730","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206.32","1206.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Clm Dst Rds 8H/4Hr","40009731","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206.32","1206.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 8X3 H 50.5Mm Ss Lcp Dst","40009732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1168.98","1168.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 8X3 H 50.5Mm Ss Lcp Dst","40009733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1168.98","1168.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Clm Dst Rds 9H/5Hl","40009734","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.23","1241.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Clm Dst Rds 9H/5Hr","40009735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.23","1241.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Clm Dst Rds 9H/4Hl","40009736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206.32","1206.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Clm Dst Rds 9H/4Hr","40009737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1206.32","1206.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn L 9X3 H 50.5Mm Ss Lcp Dst","40009738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1168.98","1168.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clmn R 9X3 H 50.5Mm Ss Lcp Dst","40009739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1168.98","1168.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds X-Art 4Hl","40009740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113.61","1113.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds Xart 4Hrl","40009741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1179.82","1179.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds X-Art 4Hr","40009742","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113.61","1113.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds X-Art/Ll","40009743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1179.82","1179.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.4X30Mm T8 Stardrv","40009744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","210.58","210.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.4X28Mm T8 Stardrv","40009745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","210.58","210.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds -20 3/4","40009746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds -20 3/3","40009747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds +20 3/4","40009748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds +20 3/3","40009749","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds -90 3/4","40009750","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds -90 3/3","40009751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds +90 3/4","40009752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds -90 2/4","40009753","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds -90 2/3","40009754","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt 2.4 Lcp Dstl Radius Str/L","40009755","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","847.2","847.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"T-Plt 2.4 Lcp Dstl Radius 3H/4","40009756","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","884.2","884.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"T-Plt 2.4 Lcp Dstl Radium 3H","40009757","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","847.2","847.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Dstl Radium Volar Rt/L","40009758","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575.45","1575.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Dstl Radium Volar Rt/S","40009759","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1487.03","1487.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Dstl Radius Volar Lt/L","40009760","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1575.45","1575.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Dstl Radius Volar Lt/S","40009761","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1487.03","1487.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X64Mm T25 Stardrv","40009762","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X62Mm T25 Stardrv","40009763","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X60Mm Hum Ft Lok","40009764","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X58Mm Hum Ft Lok","40009765","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X56Mm Hum Ft Lok","40009766","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X54Mm Hum Ft Lok","40009767","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X48Mm Hum Ft Lok","40009768","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Hum Ft Lok","40009769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Hum Ft Lok","40009770","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.0Mm Perprosth Lckng Scr 10Mm","40009771","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.07","397.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X14Mm Fem Thrd Hd","40009772","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X90Mm Thrd Conic Hd","40009773","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X85Mm Thrd Conic Hd","40009774","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X75Mm Thrd Conic Hd","40009775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X70Mm Thrd Conic Hd","40009776","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X65Mm Thrd Conic Hd","40009777","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X60Mm Thrd Conic Hd","40009778","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X55Mm Thrd Conic Hd","40009779","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X50Mm Thrd Conic Hd","40009780","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X48Mm Thrd Conic Hd","40009781","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X46Mm Thrd Conic Hd","40009782","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X44Mm Thrd Conic Hd","40009783","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X42Mm Fem Thrd Hd","40009784","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X40Mm Fem Thrd Hd","40009785","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X38Mm Fem Thrd Hd","40009786","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X30Mm Fem Thrd Hd","40009787","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X24Mm Fem Thrd Hd","40009788","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X22Mm Thrd Conic Hd","40009789","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X20Mm Fem Thrd Hd","40009790","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X18Mm Fem Thrd Hd","40009791","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"5.0Mm Perprosth Lckng Scr 8Mm","40009792","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.07","397.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X95Mm Conic Cann","40009793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X90Mm Conic Cann","40009794","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X85Mm Conic Cann","40009795","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X75Mm Conic Cann","40009796","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X70Mm Conic Cann","40009797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X65Mm Conic Cann","40009798","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X60Mm Conic Cann","40009799","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X55Mm Conic Cann","40009800","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X95Mm Conic Cann","40009801","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann Locking 7.3Mm 130Mm","40009802","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.44","559.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"L45Cm Dia0.035In Grn Hub","40009803","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","207.39","207.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Infus 4Fr L10Cm L100Cm","40009804","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","245.3","245.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X36Mm Ank Canc Can","40009805","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","421.47","421.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X44Mm Canc Cann Sht","40009806","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","245.3","245.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L382Mm D11Mm 90Deg","40009807","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1041.01","1041.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clamp Ext Fix Lg Comb Clp On","40009808","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1041.01","1041.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Separator Thromctmy Indigo 7","40009809","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","2663.65","2663.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Shnk 6.5Mm X 50Mm Invictus","40009810","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1283.66","1283.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduc Ext Tab 6.5Mm X 50Mm Inv","40009811","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L55Mm Dia9.5Mm Post","40009812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1275.93","1275.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl L55Mm Dia10.5Mm Post","40009813","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1275.93","1275.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"8.5Mm X 55Mm Polyax Cort Canc","40009814","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L50Mm Dia5.5Mm Post","40009815","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","496.93","496.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.5X100Mm Stardrv","40009816","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 5.5Mm X 50Mm","40009817","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 7.5Mm X 45Mm","40009818","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Perc Crv 5.5Mmx120Mm","40009819","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fix Ext 40Mm For Coretrak Sys","40009820","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","6282.8","6282.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl 66Mm Cerv 4 Lev Adm","40009821","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"4-5 14Mm R Fix Bear Med Cong","40009822","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Taa 21Mmx21Mmx10Cm","40009823","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","30388.18","30388.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X54Mm Cort Hex Drv","40009824","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","86.04","86.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph Tapr 6-8Mmx30Mm","40009825","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3190.05","3190.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cap Protct Grn For 6Mm Ext Fix","40009826","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","77.92","77.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 11Mm R Fix Bear Med Cong","40009827","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L4Mm Dia9Mm","40009828","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","434.85","434.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Sut Hldr Reten Slot Disp","40009829","CDM","270","RC","A4649","HCPCS","","","facility","both","","","","161.82","161.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ureth 16Fr L16In 5Cc Sil","40009830","CDM","272","RC","A4340","HCPCS","","","facility","both","","","","46.7","46.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Bx 18Ga L15Cm W/ Coax","40009831","CDM","272","RC","A4215","HCPCS","","","facility","both","","","","194.44","194.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Ext Fix Lok For 4.5/5Mm","40009832","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","634.99","634.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nut Lok Bolt For 4.5Mm Va Crv","40009833","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","441.21","441.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa Cvr 18Mmx9.5Cm","40009834","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7786.78","7786.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nrv L10Mm Dia3Mm Por","40009835","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","2322.97","2322.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X155Mm Canc Hex","40009836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dia35Mm Od12.3Mm Id7Mm Dst Ext","40009837","CDM","272","RC","A7521","HCPCS","","","facility","both","","","","177.84","177.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchr L10Mm Dia2.5Mm Sft Tiss","40009838","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Can 3.0 Mm X 30 Mm Sht Th","40009839","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","368.15","368.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 4.0Mm 18Mm S/T","40009840","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L28Mm Dia2.25Mm Rx","40009841","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L85Mm Hk D18Mm 5 H","40009842","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1107.59","1107.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X26Mm Hex Hd Can","40009843","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","348.86","348.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X24Mm Ft Canc Ft","40009844","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.63","403.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 3.5Mm X 8Mm  Synergy Xd","40009845","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Bone L125Mm Dia10Mm G Ti","40009846","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","677.03","677.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X12Mm Crucfrm Recss","40009847","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","368.15","368.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire 2.75Mm X 18Mm 5Fr X140Cm","40009848","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X130Mm Cann Lok Ss","40009849","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","377.78","377.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L34Mm Dia2.25Mm Co","40009850","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X28Mm Fem Thrd Hd","40009851","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L270Mm Dia7Mm L Hum","40009852","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2209.33","2209.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2.25Mm Radpq","40009853","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 6.5X75Mm Canc Hex","40009854","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","78.43","78.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"7Fr L100Cm Cor Crv Jr3.5 Sherp","40009855","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","119.97","119.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Dia7.0Mm L60Mm Hdlss","40009856","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1918.33","1918.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia3.5Mm Co","40009857","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2029.05","2029.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 6 H 1/4 Tblr 47Mm Ss","40009858","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","180.05","180.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Bili 5Fr L180Cm Bllln","40009859","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","501.75","501.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X26Mm Compr Canc","40009860","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.73","48.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia3Mmm Radpq","40009861","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"11Fr L10Cm Red Signal Diaph","40009862","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","180.63","180.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cort 2.0Mm X 18Mm Self Tap","40009863","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","73.38","73.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 6 H 77Mm Ss Lc-Dcp","40009864","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","276.5","276.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Recon 3.5Mm 10 140Mm","40009865","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1077.09","1077.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent + Dia2.75Mm L20Mm Everol","40009866","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2663.65","2663.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X45Mm Conic Cann Ss","40009867","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","324.73","324.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia4Mm 16Atm","40009868","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2453","2453","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4.5X30Mm Tib Cort","40009869","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","52.28","52.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ti L26Mm Od3Mm Hxlb","40009870","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2252.83","2252.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X8Mm Cort Ft Lok","40009871","CDM","278","RC","C2623","HCPCS","","","facility","both","","","","218.62","218.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eluvia Us 6X150 130 Cm","40009872","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","5031.8","5031.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 295Cc D11.5Cm P4Cm","40009873","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 330Cc D11.4Cm 4.7Cm","40009874","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 350Cc D11.6Cm 4.8Cm","40009875","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Impl 295Cc D11.5Cm P4Cm","40009876","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endscp L360Cm Svry Gllrd","40009877","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thromctmy Cath 6Fr L135Cm","40009878","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","4816.35","4816.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 13X105Mm St Lag Canc","40009879","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","731.9","731.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Lat L 6 H 112Mm","40009880","CDM","278","RC","C1887","HCPCS","","","facility","both","","","","949.54","949.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Int W15Xl12Mm Nit Compr","40009881","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2496.65","2496.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Probe Ablat 3.5Mm X 135Mm","40009882","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","400.86","400.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aprevo Alif-X L4/L5 Minus Spnl","40009883","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","36140","36140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7X80Mm Compr Hdlss","40009884","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1375.45","1375.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 4.9Mm Cann For Fixos","40009885","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","727.87","727.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 Tib Ef/Cr H16Mm L Vivacit","40009886","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia28Mm -2.7Mm Offset","40009887","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Sz 38 Thk11Mm","40009888","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 7 Thk10Mm Knee","40009889","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplt Tib Sz 7 Ap56Mm Ml80Mm","40009890","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L12Mm Dia1.2Mm Otw","40009891","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L12Mm Dia1.2Mm Rx","40009892","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L8Mm Dia1.2Mm Rx","40009893","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Cor Hydrphlc Coat","40009894","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","3034.39","3034.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L8Mm Dia3.75Mm Otw","40009895","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.7","200.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L8Mm Dia3.25Mm Rx","40009896","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1386.1","1386.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L6Mm Dia3.25Mm Otw","40009897","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.7","200.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Ext Fix L110Mm Pin Sprd","40009898","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2785.31","2785.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Ext Fix L160Mm Pin Sprd","40009899","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3199.07","3199.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 12 H 1/3 Tblr","40009900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","382.38","382.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 7 R Knee","40009901","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X14Mm Cort Ft Ti Lp","40009902","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","283.21","283.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 5 Thk9Mm Knee X3","40009903","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz5 Ap49Mm","40009904","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 L Knee","40009905","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Sz 35 Thk10Mm","40009906","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz 6 Ap 52Mm Ml","40009907","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Size 6 Thk11Mm Knee","40009908","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 6 R Knee","40009909","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tn Ti Fus Plt M","40009910","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3069.47","3069.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0 Str Ti Plt 5 H","40009911","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1366.73","1366.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 28 Mm D","40009912","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 26 Mm D","40009913","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 24 Mm D","40009914","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Va Scr Len 20 Mm D","40009915","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","526.17","526.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Ti Crtx Scr Lgth10Mm Blu","40009916","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Ti Crtx Scr Lgth12Mm Blu","40009917","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Ti Crtx Scr Lgth22Mm Blu","40009918","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Ti Var Angl Scr Lgth22Mm","40009919","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","526.17","526.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X34Mm Stardrv Rec","40009920","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X36Mm Stardrv Rec","40009921","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.6 Mm Drlbt For Std Tech","40009922","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","419.46","419.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0 Mm Drlbt For Lag Tech","40009923","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","419.46","419.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.7 Mm Drlbt For Std Tech","40009924","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","419.46","419.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 6 R Knee","40009925","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3507","3507","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mini & Mic Plt Thrd Len 15Mm","40009926","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sm Plt Thrd Len 10Mm","40009927","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sm Plt Thrd Len 15Mm","40009928","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"16Mm L Fix Bear Med Cong Vivac","40009929","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L25Mm Dia3.3Mm Disp","40009930","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3475","3475","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ret Viscera L W6 3/8Xl9 5/8In","40009931","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","75.33","75.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl H8-10Mm 7Deg Lng St","40009932","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl W15.5Xh6X3.2Mm D14Mm","40009933","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2338","2338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aprevo Fix","40009934","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2672","2672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Polyax 6.5Mm X 55Mm","40009935","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post No1 3.5X30Mm","40009936","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L45Mm Dia5.5Mm Ti","40009937","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","734.76","734.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Ti Vi2 5.5Mm X 90Mm","40009938","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","734.76","734.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Cerv 9Mm 1 Level","40009939","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med 35Mm Sm 1 Hnd Appl","40009940","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Med 50Mm Sm 1 Hnd Appl","40009941","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","3089.5","3089.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 H11Mm R Vivacit-E Med Con","40009942","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lapidus Ti Plate Medial Short","40009943","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3560.28","3560.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Va Scr Len 30 Mm Dk","40009944","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","526.17","526.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 20 Mm D","40009945","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 18 Mm D","40009946","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Compression Wire 1.6Mm","40009947","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lapidus Ti Plt 0 Mm Stp L","40009948","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3560.28","3560.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Conn Sht Insrt Hndl Cann","40009949","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","923.04","923.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Support For Vascular","40009950","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","8333.05","8333.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spinal 5Mm Zero","40009951","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2922.5","2922.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnal Acss W16Xh5Xl14Mm","40009952","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3256.5","3256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr 11X30Mm Biocompost","40009953","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.5X32Mm Post Cerv","40009954","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1414.76","1414.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia22.225Mm +7 Offset","40009955","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","951.9","951.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasq External Support","40009956","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","8333.05","8333.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Staple Bne Fix W15Xl12In Nit","40009957","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3164.65","3164.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl 3Mm For Comphsve Ft","40009958","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","176.17","176.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Harvester Bne Grft 6Mm","40009959","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","943.55","943.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7X45Mm Compr Hdlss","40009960","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1918.33","1918.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X40Mm Compr Hdlss","40009961","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","851.03","851.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Sm L58Mm St L Calcnl","40009962","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1948.81","1948.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Compression Wire 1.6Mm","40009963","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","179.07","179.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X36Mm Stardrv Rcs","40009964","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X42Mm Stardrv Rcs","40009965","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X55Mm Stardrv Rcs","40009966","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X50Mm Stardrv Rcs","40009967","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X70Mm Stardrv","40009968","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5.5X75Mm Stardrv","40009969","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","953.77","953.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L 14 H Lo Bend 239Mm","40009970","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2200.17","2200.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa 28.5Mmx4.5Cm","40009971","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7544.92","7544.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa Cvr 32Mmx4.5Cm","40009972","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7544.92","7544.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spnl Crd Stim 1X8 Two Trl Ld","40009973","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","1653.3","1653.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 L Knee","40009974","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa 16Mmx10Mmx124Mm","40009975","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6638.64","6638.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Valve Aort Dia20Mm Resilia Tis","40009976","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","47260","47260","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix 500Mm 11Mm C Fbr","40009977","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","416.68","416.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acet Id46Mm Sz F Mdm","40009978","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2338","2338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X36Mm Canc Hex Drv","40009979","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","381.33","381.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X70Mm Hindfoot Cor","40009980","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shell Acet Sz F Dia56Mm 13 H","40009981","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4306.22","4306.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Acet Od52Mm Id28Mm Mob","40009982","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L260Cm Dia0.035In","40009983","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","512.9","512.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X24Mm Preferred","40009985","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4X24Mm Preferred","40009986","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl L16Mm Dia4Mm Cocr","40009987","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Occptl 4.5X6Mm","40009988","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","947.75","947.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cd H16Mm L Knee Vivacit-E Cr","40009989","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.18","2282.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conn Nrv L10Mm Dia4Mm 100 Mic","40009990","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","2322.97","2322.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fix L14Mm Rnd Concave","40009991","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","499.52","499.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es M 1Cm X 1Cm Shft","40009992","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","73.69","73.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L440Mm D10Mm Nk 130Deg","40009993","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3323.28","3323.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X24Mm Lag Cort T8","40009994","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.37","965.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X10Mm Polyax Ank","40009995","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","850.97","850.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X20Mm Ang Coc","40009996","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R Dst Fib 5H Lok Ss","40009997","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1210.75","1210.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Perc Crv 5.5Mm X 80Mm","40009998","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Glen Sz 3 L 4 Peg Mod","40009999","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2915.2","2915.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 5.5Mm 1-3 Lev Perc","40010000","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spcr Spnl Lm 20D 7Mmx10Mmx30Mm","40010002","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7X28Mm Ank Cort Ft","40010003","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","125.55","125.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 2.7X36Mm Cort T8","40010004","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","235.31","235.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn 8H 76Mm Mod 2.7Mm Scr","40010005","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","828.78","828.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bn Cndyl 20 St Crv 405Mm","40010006","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3558.96","3558.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X36Mm Stdrv Rcss Cn","40010007","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pin Bttrs L16Mm Dia1.8Mm","40010008","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","245.79","245.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X80Mm Cort Hdlss Nl","40010009","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","993.65","993.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X30Mm Cort Ti Nail","40010010","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X35Mm Cort Ti Nail","40010011","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X75Mm Cort Hdlss Nl","40010012","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","993.65","993.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl 5.5X50Mm Lrd Ticp Mis","40010013","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl Calib 4.2Mm","40010014","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","947.75","947.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H27Mm Dia46Mm Curv","40010015","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2637.26","2637.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im Hidfoot 11.5Mm X 210Mm","40010016","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","17375","17375","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brst Imp 500Cc Dia13.1Cm 5.2Cm","40010017","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Anchr Fbr Wire 3Mm 3.5Mm","40010018","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2496.65","2496.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L285Mm Dia9Mm Tib Tn","40010020","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2620.83","2620.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia6.4Mm Pat Fem","40010021","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","224.56","224.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 H12Mm L Vivacit-E Med Con","40010022","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fn Md Sk 6.5Mmx45Mm","40010023","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1283.66","1283.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im 9X400Mm 5Deg Bend Fem","40010024","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3131.45","3131.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth 10Mm Extn Dia9.5Mm","40010025","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","314.7","314.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 425Cc Dia13.5Cm","40010026","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Impl Mobi-C 1315 H4.5","40010028","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","7506","7506","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst 490Cc Dia13.6Cm","40010029","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","613.25","613.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 465Cc Dia13.3Cm","40010030","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst Od11.6Cm 215Ml","40010031","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst Od12.2Cm 255Ml","40010032","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sizer Brst Od11.8Cm 235Ml","40010033","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X45Mm","40010034","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6255","6255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X40Mm","40010035","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6255","6255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X35Mm","40010036","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6255","6255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L38Mm Ant Cerv","40010037","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1753.5","1753.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X46Mm Stardrv Rcs","40010038","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cage Spnl W15.5Xh6X4Mm D12Mm","40010039","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2338","2338","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Va Sd 4.0Mm X 18Mm","40010040","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.86","1074.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Ang Sd 4.0Mmx18Mm","40010041","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.86","1074.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"5/7Fr X 37Cm Cath 20Ml Ll 10Ml","40010042","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","196.53","196.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Ball Tip 3Mm X 600 Mm St","40010043","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","880.85","880.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reamer Stp 8.5Mm","40010044","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1103.85","1103.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Surg L20In Nit Blnt Tip","40010045","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","212.96","212.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L650Mm Dia1.4Mm Nitinol","40010046","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","240.84","240.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"1St Mtp Ti Fus Plt Sm 5 Deg R","40010047","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3256","3256","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload Stpl Blu 45Mm 3.5Mm 6 R","40010048","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","468.3","468.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Pacemkr Cap Transcatheter","40010049","CDM","275","RC","C1786","HCPCS","","","facility","both","","","","14942.5","14942.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vte Price Per Procedure","40010050","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","16680","16680","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dvt Price For Procedure","40010051","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","12510","12510","","","","","","","","","","","","","Gross Charge Type: Standard"
"8.5F Shth W/ Crv Viz Lgc","40010052","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","1763.52","1763.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth Guid 11.5X8.5Fr L71Cm M","40010053","CDM","272","RC","C1766","HCPCS","","","facility","both","","","","1763.52","1763.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep 5Fr L110Cm 1Mm Tip 5Mm","40010054","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card 59.5Cc W83.1Xh69.1M","40010055","CDM","275","RC","C1722","HCPCS","","","facility","both","","","","27522","27522","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep 6Fr L92Cm 1Mm 2-8-2Mm","40010056","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","888.44","888.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ep 7Fr L115Cm Tip 2Mm","40010057","CDM","272","RC","C1730","HCPCS","","","facility","both","","","","1012.02","1012.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 1-7-4Mm 7Fr L115Cm Electr","40010058","CDM","272","RC","C1732","HCPCS","","","facility","both","","","","3370.75","3370.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Defib L65Cm Dst Tip 150Mm","40010059","CDM","278","RC","C1777","HCPCS","","","facility","both","","","","4051.85","4051.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card Df4 Is1 Hf-T Conn","40010060","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","19738","19738","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Cardiac 3 Chmbr Df4 Is4","40010061","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","24708.94","24708.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Rx C-Pcsy-830-Lock","40010062","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","416.56","416.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Pa 6Fr L110Cm Dia9Mm 1Cc","40010063","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","323.35","323.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth 6Fr L20Cm 0.018In L65Cm","40010064","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","183.97","183.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X28Mm Lag Cort","40010065","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.36","965.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X42Mm Canc Cann Lng","40010066","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.91","364.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X42Mm Canc Cann Lng","40010067","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.91","364.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X30Mm Lag Cort T8","40010068","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","965.36","965.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X36Mm Compr Cann","40010069","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","945.52","945.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L44Mm Dia3.5Mm Prox","40010070","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","298.57","298.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.4X34Mm Cort Ft St","40010071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","124.68","124.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X58Mm Ft Cort Hex","40010072","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","62.83","62.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X16Mm Cort Ft St","40010073","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.42","77.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X18Mm Compr Canc","40010074","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.73","48.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Dia0.07In Judkin","40010075","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","3516.7","3516.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Dia0.07In Judkin","40010076","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 7Fr L100Cm Tp L0.1In","40010077","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X20Mm Stardrv Rec","40010078","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X34Mm Hum Ft Lok","40010079","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X36Mm Hum Ft Lok","40010080","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X56Mm Hindfoot Cor","40010081","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X64Mm Hindfoot Cor","40010082","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X74Mm Hindfoot Cor","40010083","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X18Mm Preferred","40010084","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nc Ti Fusion 5 Hole, Long Left","40010085","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3069.47","3069.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X14Mm Canc Hex Hd","40010086","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X16Mm Canc Hex Hd","40010087","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X18Mm Dst Fem Cort","40010088","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.07","397.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X65Mm Dst Fem Cort","40010089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","397.07","397.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Cerv Facet Ti Ally","40010090","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1102.2","1102.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 6Mm X 19Mm","40010091","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4567.54","4567.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 29Mm","40010092","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 59Mm","40010093","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 29Mm","40010094","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 39Mm","40010095","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 59Mm","40010096","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L8Mm Dia2.4Mm Ss St","40010097","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","210.58","210.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X24Mm Compr Mtph","40010098","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.55","113.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R 3X7 H T Plt 96Mm","40010099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","797.38","797.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Flexband Twist 0.12","40010100","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7638.05","7638.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es L12Xw2Cm Od2Cm L","40010101","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","294.49","294.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Loop W2Cm D1.5Cm L","40010102","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","294.49","294.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Es W1.5Cm D1.5Cm Shf","40010103","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","294.49","294.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Bone Biopsy Size 2 10Ga","40010104","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","200.25","200.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retractor Iris Disp Nyl Adj Si","40010105","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","90.4","90.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Skin Mammo 3D Digitial","40010106","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","155.96","155.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Skin Mammo 3D Digitial","40010107","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","136.85","136.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Stnt Cvr 8Mm X 29Mm","40010108","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5523.86","5523.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Skin Mammo 3D Digitial","40010109","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","134.59","134.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Skin Mammo 3D Digitial","40010110","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","141.03","141.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Support","40010111","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","8333.05","8333.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix L650Mm Dia11Mm C","40010112","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","450.66","450.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Ext Fix 550Mm 11Mm C Fbr","40010113","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","450.66","450.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia8Mm","40010114","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 34 Mm","40010115","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5 Mm Ti Cort Scr Len 32 Mm","40010116","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","182.75","182.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L10Mm Dia3Mm Nonlock","40010117","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","267.6","267.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cardiology Minor Surg, 1St Hr","40010118","CDM","360","RC","","","","","facility","both","","","","57535","57535","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sub Bne Grft Ptty 4Cc Fbrgrft","40010119","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trocar Spcmker Balloon","40010120","CDM","272","RC","","","","","facility","both","","","","2967.5","2967.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L90Mm Dia3.5Mm","40010121","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","617.71","617.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacemaker Preperitoneal Disse","40010122","CDM","272","RC","","","","","facility","both","","","","1208.75","1208.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Pst 4.5X28Mm Polyax","40010123","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 3.5X16Mm Preferred","40010124","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1932.19","1932.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Dia32Mm Nk +3Mm Offst","40010125","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","962.36","962.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ent Den Surg, Minor 1St Hour","40010126","CDM","360","RC","","","","","facility","both","","","","48801","48801","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liner Acet Dia32Mm Sz 23 10Deg","40010127","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1441.38","1441.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy Passive","40010128","CDM","272","RC","","","","","facility","both","","","","2163.73","2163.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Acutrak Mini 2 Long","40010129","CDM","272","RC","","","","","facility","both","","","","861","861","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wire Guide Single Trocar .045","40010130","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","63","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Acutrak Mini 2","40010131","CDM","272","RC","","","","","facility","both","","","","777","777","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 24Mm Mini Acutrak","40010132","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","891","891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Microfix","40010133","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","915.6","915.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ent Major Surg, 1St Hr","40010134","CDM","360","RC","","","","","facility","both","","","","78013","78013","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler ,Sureform  60,Spu,1S40","40010135","CDM","272","RC","","","","","facility","both","","","","834.75","834.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload.Sureform 60.3.5 Blue.6-","40010136","CDM","272","RC","","","","","facility","both","","","","483","483","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload,Sureform 60,4.3 Green,6","40010137","CDM","272","RC","","","","","facility","both","","","","483","483","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapler,Sureform  45, 1S4000","40010138","CDM","272","RC","","","","","facility","both","","","","857.85","857.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload,Stapler 45,4.3 Green,4-","40010139","CDM","272","RC","","","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload,Stapler 45,3.5 Blue,6-R","40010140","CDM","272","RC","","","","","facility","both","","","","389.34","389.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reload,Stapler 45,2.5 White ,6","40010141","CDM","272","RC","","","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eye Minor Surg, 1St Hr","40010142","CDM","360","RC","","","","","facility","both","","","","88673","88673","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Cover Accessory","40010143","CDM","272","RC","","","","","facility","both","","","","50","50","","","","","","","","","","","","","Gross Charge Type: Standard"
"8 Mm Bladeless Obturator","40010145","CDM","272","RC","","","","","facility","both","","","","75","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"8 Mm Bladeless Obturator, Long","40010146","CDM","272","RC","","","","","facility","both","","","","75","75","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 - 8 Mm Reducer","40010147","CDM","272","RC","","","","","facility","both","","","","63","63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluorescence Imaging Pack, Is3","40010148","CDM","272","RC","","","","","facility","both","","","","409.5","409.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Instrument Ann Drape","40010149","CDM","272","RC","","","","","facility","both","","","","130","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl 58Mm Cerv 4 Lev Adm","40010151","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fix Ang 4Mm X 18Mm","40010152","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.86","1074.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Fix Ang 4.3Mm X 16Mm","40010153","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.86","1074.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L40Mm Dia3.3Mm Disp","40010154","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","305.51","305.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 2 Thk11Mm Knee","40010155","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 2 Thk9Mm Knee","40010156","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5Mm X 60Mm","40010157","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 R Knee","40010158","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"General Minor Surg, 1St Hr","40010159","CDM","360","RC","","","","","facility","both","","","","71803","71803","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 4 Thk11Mm Knee","40010160","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Fem Rg Dia12Xl420Mm 10Deg","40010161","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3131.45","3131.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dynaforce Superelastic Bne Stp","40010162","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit Size Unspecified","40010163","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","244.19","244.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrixsternum X-Pl Sm 8 Ho","40010164","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1357.38","1357.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrixsternum Straight Pl 6 Ho","40010165","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1302.6","1302.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ovitex 1S Reinf Bioscaffold","40010166","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3002.4","3002.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"General Major Surg, 1St Hr","40010167","CDM","360","RC","","","","","facility","both","","","","110654","110654","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurostim Torq Wrnch","40010168","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thor 32Fr L23In R Ang Clr","40010169","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","208.37","208.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 5.5X50Mm","40010170","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 6.5X55Mm","40010171","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 7.5X45Mm","40010172","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Screw Spnl Perla Tl","40010173","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","446","446","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X140Mm Pst","40010174","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gynecology Minor Surg, 1St Hr","40010175","CDM","360","RC","","","","","facility","both","","","","83160","83160","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 4.5X45Mm","40010176","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 7.5X50Mm","40010177","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2254.5","2254.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.5X85Mm Compr Hdlss","40010180","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.02","1079.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.5X75Mm Compr Hdlss","40010181","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.02","1079.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L220Mm 9 H Nonsteril","40010182","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2416.57","2416.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gynecology Major Surg, 1St Hr","40010183","CDM","360","RC","","","","","facility","both","","","","101947","101947","","","","","","","","","","","","","Gross Charge Type: Standard"
"Knee Fibertak Bttn","40010184","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1103.85","1103.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Mtp R 0Deg Valgus","40010185","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3331.65","3331.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X14Mm Cort Mtp Lp","40010186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X16Mm Cort Mtp Lp","40010187","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X14Mm Compr Va Ft","40010188","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X16Mm Compr Va Ft","40010189","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","657.85","657.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Cerv 42Mm 3 Lev","40010190","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4998.44","4998.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Major Surg, 1St Hour","40010191","CDM","360","RC","","","","","facility","both","","","","121635","121635","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Hum H21Mm Od64Mm Id54Mm","40010192","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2637.26","2637.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuro Minor Surg, 1St Hr","40010193","CDM","360","RC","","","","","facility","both","","","","85513","85513","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 1.8Mm","40010194","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","847.4","847.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Biologic 2S 16 X 20Cm","40010195","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","10675.2","10675.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thor 20Fr L22In Blu Radpq","40010196","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","20.34","20.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thor 28Fr L23In Clr Pvc","40010197","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","20.88","20.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"W15Xh4.5Mm D12Mm Cnvx Ti Life","40010198","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L51Mm Thk1.9Mm Ant","40010199","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2359.71","2359.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7X75Mm Hdlss Ft","40010200","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","312.2","312.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X95Mm Canc Hex","40010201","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X50Mm Canc Hex","40010202","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X55Mm Canc Hex","40010203","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 6.5Mm X 110Mm W/32Mm","40010204","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","502.29","502.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann 6.5Mm X 140Mm W/32Mm","40010205","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm 4Fr L60Mm Dia3Mm","40010206","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L100Mm Dia7Mm","40010207","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Polyaxial Screw 3.5Mm X 16Mm","40010208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1414.76","1414.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ortho Minor Surg, 1St Hr","40010209","CDM","360","RC","","","","","facility","both","","","","100480","100480","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fav Angl Screw Cc 3.5Mm X 14Mm","40010210","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1452.65","1452.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L40Mm Dia7Mm","40010211","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L150Mm Dia6Mm","40010212","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L80Mm Dia6Mm","40010213","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L100Mm Dia5Mm","40010214","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L150Mm Dia3Mm","40010215","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 5Fr L70Cm Blln","40010216","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","292.58","292.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ortho Major Surg, 1St Hr","40010217","CDM","360","RC","","","","","facility","both","","","","121429","121429","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 3X20Mm 90Cm 0.018In","40010218","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","219.77","219.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L90Cm L20Mm Dia1.5Mm","40010219","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","724.75","724.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.5Mm","40010220","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3.25Mm","40010221","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia3Mm","40010222","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca Blln L20Mm Dia2.5Mm","40010223","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","947.75","947.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 11Fr 8Fr L3Mm D20Mm","40010224","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","390.81","390.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ortho Scope Surg, 1St Hr","40010225","CDM","360","RC","","","","","facility","both","","","","96317","96317","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil Blln Ptv 22.0Mmx3.0Cm","40010226","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1105.57","1105.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 9Fr L100Cm L3Cm Dia25Mm","40010227","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1105.57","1105.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia4Mm","40010228","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L220Mm D3.5Mm","40010229","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm D3.5Mm","40010230","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm 4Fr L100Mm D3.5Mm","40010231","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm 4Fr L60Mm Dia3.5Mm","40010232","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Podiatry Minor Surg, 1St Hr","40010233","CDM","360","RC","","","","","facility","both","","","","72306","72306","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L220Mm Dia3Mm","40010234","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia3Mm","40010235","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L220Mm D2.5Mm","40010236","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1003.5","1003.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm D2.5Mm","40010237","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm 4Fr L100Mm D2.5Mm","40010238","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm 4Fr L60Mm Dia2.5Mm","40010239","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L150Mm Dia2Mm","40010240","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Minor Surg, 1St Hr","40010241","CDM","360","RC","","","","","facility","both","","","","69883","69883","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L40Mm D1.5Mm","40010242","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","421.8","421.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia3.5Mm Polyx","40010243","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Dst Lat 4 H 89Mm","40010244","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1244.99","1244.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"11Mm L Fix Bear Med Cong","40010245","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"14Mm L Fix Bear Med Cong","40010246","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Tib Med Dst R 8 H St","40010247","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2035.81","2035.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcp 5-H 3.5Mm 64Mm","40010248","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","257.21","257.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X24Mm Compr Canc","40010249","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.73","48.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"L-Plt 2.4 Lcp Dstl Rds +90 3/3","40010250","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds +90 2/4","40010251","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","861.67","861.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"L Plt 2.4 Lcp Dstl Rds +90 2/3","40010252","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds X-Art/L","40010253","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113.61","1113.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlr Dstl Rds X-Art/Rl","40010254","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1179.82","1179.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plt Lcp Vlar Dstl Rds X-Art/R","40010255","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1113.61","1113.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L20Mm Dia10Mm","40010256","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L60Mm Dia3Mm","40010257","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urology Minor Surg, 1St Hr","40010258","CDM","360","RC","","","","","facility","both","","","","71996","71996","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L20Mm Dia7Mm","40010259","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L40Cm L40Mm Dia6Mm","40010260","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L40Cm L20Mm Dia8Mm","40010261","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L40Cm L40Mm Dia12Mm","40010262","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L40Cm L20Mm Dia6Mm","40010263","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm D3.75Mm","40010264","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","124.29","124.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L200Mm Dia7Mm","40010265","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urology Major Surg, 1St Hr","40010266","CDM","360","RC","","","","","facility","both","","","","115075","115075","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L60Mm Dia7Mm","40010267","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L40Mm Dia9Mm","40010268","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","423.7","423.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X32Mm Fem Thrd Hd","40010269","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R 4 H T Plt 63Mm Ob","40010270","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","702.52","702.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 12 H 1/3 Tblr","40010271","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","172.95","172.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 10 H 1/3 Tblr","40010272","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","166.93","166.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm L30Mm Dia4Mm","40010273","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","195.3","195.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vascular Minor Surg, 1St Hr","40010274","CDM","360","RC","","","","","facility","both","","","","82093","82093","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hi Prss 2.0Mm X 15Mm X 145Cm","40010275","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hi Prss 2.75Mm X 20 M X 145Cm","40010276","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hi Prss 3.75Mm X 20Mm X 145Cm","40010277","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia4Mm","40010278","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia3Mm","40010279","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2663.65","2663.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X7 H T Plt 96Mm Obl","40010280","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","798.99","798.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L 3X5 H T Plt 74Mm","40010281","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","736.28","736.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vascular Major Surg, 1St Hr","40010282","CDM","360","RC","","","","","facility","both","","","","143129","143129","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L120Cm L40Mm Dia14Mm","40010283","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X28Mm St Xl25 Recss","40010284","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X30Mm Lp Lok St","40010285","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L32Mm Dia5Mm Lok Lp","40010286","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X36Mm St Xl25 Recss","40010287","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X40Mm St Xl25 Recss","40010288","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X44Mm St Xl25 Recss","40010289","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","628.5","628.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgery Additional Minute(S)","40010290","CDM","360","RC","","","","","facility","both","","","","708","708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X50Mm Canc Cann Lng","40010291","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","381.33","381.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5Mmx50Mm Masada","40010292","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5Mmx45Mm Masada","40010293","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tulip Spnal Polyaxl Ti6Al4Veli","40010294","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal Tulip T30 Masada","40010295","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L90Mm Od5.5Mm Ticp","40010296","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urgoclean Ag 4 X 5","40010297","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","38.08","38.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urgoclean Ag 3 X 3","40010298","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","20.71","20.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tip Sur Drvr 3Mm Sld Hex Qr","40010299","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","871.74","871.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Thermoablation 6Fr L60Cm","40010300","CDM","278","RC","C1888","HCPCS","","","facility","both","","","","590.95","590.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X20Mm Stardrv Recss","40010301","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X22Mm Stardrv Recss","40010302","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X24Mm Stardrv Recss","40010303","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Compr Sht Tib Nail","40010304","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","568.2","568.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Compr Lng Tib Nail","40010305","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","686.48","686.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Sur Wire Ns Lng Mult H","40010306","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1520.57","1520.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drl L280Mm Dia4.3Mm Qc","40010307","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","608.39","608.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleeve Drl L130Mm Dia7.2/4.3Mm","40010309","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","790.74","790.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Va St 4.0Mm X 14Mm","40010310","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1074.86","1074.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 2 L Cr","40010311","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2672","2672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Thk9Mm D29Mm X3","40010312","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1002","1002","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz 2 Univ Knee","40010313","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Augment Tib Sz 2 Thk5Mm Rl Lm","40010314","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1668.33","1668.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne L 3X4 H T Plt 63Mm","40010315","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","705.73","705.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X36Mm Compr Ft Hdls","40010317","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","732.11","732.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X50Mm Stardrv Reces","40010318","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interbody Aprevo Tlif-O L3/L4","40010319","CDM","278","RC","C1831","HCPCS","","","facility","both","","","","36140","36140","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 6.5Mmx55Mm Masada","40010320","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spinal 7.5Mmx40Mm Masada","40010321","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.5Mm Sft Tiss","40010322","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1118.9","1118.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L120Cm L40Mm Dia16Mm","40010323","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","579.8","579.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L120Cm L40Mm Dia18Mm","40010325","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","452.31","452.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia7Mm","40010326","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.88","200.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia4Mm","40010327","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.88","200.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L20Mm Dia4Mm","40010328","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","200.88","200.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Rad Dst L 6X5 H 57Mm","40010329","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1334.5","1334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia5Mm","40010330","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.85","167.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L140Cm L10Mm Dia1.5Mm","40010331","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","195.3","195.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone R 3X5 H T Plt 74Mm","40010333","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","733.05","733.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 9 H Str 11X116Mm Ss","40010334","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","316.68","316.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath  L75Cm 5Fr L20Mm Dia6Mm","40010335","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L300Mm Dia6Mm","40010336","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2087.5","2087.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L250Mm Dia6Mm","40010337","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","646.7","646.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L200Mm Dia6Mm","40010338","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","602.1","602.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L150Mm Dia6Mm","40010339","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","446","446","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5-6Fr L130Mm L250Mm D5Mm","40010341","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","2171","2171","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L150Mm Dia5Mm","40010342","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","602.1","602.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L200Mm Dia5Mm","40010343","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.0-3.5X210X150 Amphrn Bln Ct","40010344","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","201.37","201.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.25 Mm X 8 Mm X 145 Cm","40010345","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.5X3.0X210X150 Amphrn Bln Ct","40010346","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","802.8","802.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0-2.5X210X150 Amphrn Bln Ct","40010347","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","802.8","802.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm L120Mm Dia3.5Mm","40010348","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","802.8","802.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5X80X150 Amphrn Bln Cth Otw","40010349","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"3.5X40X150 Amphrn Bln Cth Otw","40010350","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L120Mm Dia3Mm","40010351","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"3X80X150 Amphrn Bln Cth Otw","40010352","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"3X40X150 Amphrn Bln Cth Otw","40010353","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.5X120X150 Amphrn Bln Cth Otw","40010354","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.5X80X150 Amphrn Bln Cth Otw","40010355","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm L40Mm Dia2.5Mm","40010356","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L120Mm Dia2Mm","40010358","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"2X80X150 Amphrn Bln Cth Otw","40010359","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"2X40X150 Amphrn Bln Cth Otw","40010360","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L20Mm L150Mm Dia1.5Mm","40010361","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Fr L80Cm L40Mm Dia10Mm","40010362","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia9Mm","40010363","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 2 Lumn 6 Fld Dsgn","40010364","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"8X60X80 Admrl Xtrme Pta Bln","40010366","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Fr L80Cm L40Mm Dia8Mm","40010367","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L80Mm Dia7Mm","40010368","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","876.39","876.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"7X80X80 Admrl Xtrme Pta Bln","40010369","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"7X60X130 Admrl Xtrme Pta Bln","40010370","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"7X60X80 Admrl Xtrme Pta Bln","40010371","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"7X40X130 Admrl Xtrme Pta Bln","40010372","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L80Cm L40Mm Dia7Mm","40010374","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"6X80X130 Admrl Xtrme Pta Bln C","40010375","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"6X80X80 Admrl Xtrme Pta Bln C","40010376","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","201.37","201.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L60Mm Dia6Mm","40010377","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L80Cm L60Mm Dia6Mm","40010378","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L40Mm Dia6Mm","40010379","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"6X40X80 Admrl Xtrme Pta Bln Ca","40010380","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L120Mm Dia5Mm","40010382","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L80Mm Dia5Mm","40010383","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L80Cm L80Mm Dia5Mm","40010384","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"5X60X130 Admrl Xtrme Pta Bln C","40010385","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"5X60X80 Admrl Xtrme Pta Bln C","40010386","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L130Cm L40Mm Dia5Mm","40010387","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L80Cm L40Mm Dia5Mm","40010388","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"8X60X80 Reef Hp Pta Bln Cath","40010389","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Hp L80 Cm L60 Mm Od7 Mm","40010390","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"7X40X80 Reef Hp Pta Bln Cath","40010391","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"6X80X120 Reef Hp Pta Bln Cath","40010392","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monitor Card Biomonitor Iiim","40010393","CDM","278","RC","C1764","HCPCS","","","facility","both","","","","5560","5560","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.25 Mm X 12 Mm X 145 Cm","40010394","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.25 Mm X 15 Mm X 145 Cm","40010395","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 3.5 Mm X 12 Mm X 145 Cm","40010396","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L140Cm L6Mm Dia1.5Mm","40010397","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","195.3","195.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"6X60X80 Reef Hp Pta Bln Cath","40010398","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia6Mm","40010399","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"5X80X80 Reef Hp Pta Bln Cath","40010400","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L60Mm Od5Mm","40010401","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"5X40X80 Reef Hp Pta Bln Cath","40010402","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L81Cm L60Mm Od4Mm","40010403","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia4Mm","40010404","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia8Mm","40010405","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","412.55","412.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L143Cm L6Mm Dia3.25Mm","40010406","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","713.6","713.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pta Pro Endovasc. Balloon 5Fr","40010407","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","492.05","492.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 8Fr L75Cm L40Mm Dia18Mm","40010408","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 8Fr L75Cm L4Cm Dia16Mm","40010409","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 7Fr L45Cm L40Mm Dia14Mm","40010410","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","669","669","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L20Mm Dia12Mm","40010411","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","297.95","297.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L150Mm Dia7.3Mm Thrd","40010412","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X125Mm Canc Hex","40010413","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 7.3X95Mm Canc Hex","40010414","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X95Mm Canc Hex","40010415","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X90Mm Conic Cann","40010416","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X85Mm Conic Cann","40010417","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X80Mm Conic Cann","40010418","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X75Mm Conic Cann","40010419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X70Mm Conic Cann","40010420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X65Mm Conic Cann","40010421","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X60Mm Conic Cann","40010422","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X55Mm Conic Cann","40010423","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X50Mm Conic Cann","40010424","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","487.1","487.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann Locking 7.3Mm 145Mm","40010425","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.44","559.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X140Mm Hex Drv","40010426","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.44","559.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cann Locking 7.3Mm 135Mm","40010427","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","559.44","559.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X36Mm Fem Thrd Hd","40010428","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Bio Ovine Rumen 10Cmx17Cm","40010429","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Bio W10Xl12Cm Ovine Rumen","40010430","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1903.8","1903.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fav 9.0Mm X 100Mm","40010431","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3189.83","3189.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Pt Spcfc Cocr 5.5Mm","40010432","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2192","2192","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Patient Specific Design","40010433","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2641","2641","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl Ant Cerv 2 Lev 38Mm","40010434","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1786.32","1786.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Cerv 16X7X14Mm 7Dg","40010435","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2922.5","2922.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insignia Hexalobe Screw Fix","40010436","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","206.72","206.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hip 3 H 62Mm 140Deg","40010437","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","942.04","942.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hip 2 H 46Mm 130Deg","40010438","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","942.04","942.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Lag Dhs/Dcs 12.7Mmx145Mm","40010439","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","599.62","599.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcs Set 14Degree Plate","40010440","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1478.4","1478.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcs 10H 95 Deg 178Mm","40010441","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1308.65","1308.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Dcs 6H 95 Deg 114Mm","40010442","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1308.65","1308.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Va Ft Lok","40010443","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.01","250.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X4Mm Crss Cort","40010444","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2493.78","2493.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pectoralis 4 Button Drill Pin","40010445","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2755.5","2755.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Dst Tib","40010446","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.42","77.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X100Mm Cort Ft","40010447","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.75","51.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrografin 66-10 Sol","40010448","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","469.64","469.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Cort Ft","40010449","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","84.45","84.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L190Cm Dia0.010/0.014In","40010450","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2.75Mm Cath","40010451","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2807.84","2807.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L100Mm Dia6Mm Cat","40010452","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2299.59","2299.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia5Mm Co Plat","40010453","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia5Mm Co Plat","40010454","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Athrctmy Cath 6Fr L135Cm Gwire","40010455","CDM","272","RC","C1724","HCPCS","","","facility","both","","","","4865","4865","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace 6Fr L52Cm 10Mm Spc","40010456","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace 5.7Fr L65Cm Av Polyr","40010457","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","889.74","889.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L10Cm Dia11Mm","40010458","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5112.42","5112.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L15Cm Dia10Mm","40010459","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5717.07","5717.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace 6Fr L58Cm 10Mm Spc","40010460","CDM","275","RC","C1898","HCPCS","","","facility","both","","","","356.8","356.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endopros L10Cm Dia10Mm","40010461","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5112.42","5112.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia2.5Mm Cath","40010462","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","189.55","189.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admiral Av 9Frx12Mmx40Mmx80Cm","40010463","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Paclitaxel Coat 7Mmx60Mm","40010464","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eluvia 6Mmx120Mmx130Cm","40010465","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3892","3892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Eluvia 6Mmx100Mmx130Cm","40010466","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5212.5","5212.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Fr L138Cm L12Mm Dia4Mm","40010467","CDM","272","RC","C1761","HCPCS","","","facility","both","","","","6533","6533","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Fr L138Cm L12Mm Dia3.5Mm","40010468","CDM","272","RC","C1761","HCPCS","","","facility","both","","","","6533","6533","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Del L150Cm Dia0.25In Tip","40010469","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1085.5","1085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dia0.035In L65Cm 30Deg","40010470","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","483.02","483.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L90Cm Dia0.018In Ss Angle","40010471","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","522.6","522.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Periph Accs Nd 21Ga L7Cm L50Cm","40010472","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","3156.3","3156.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L250Mm Dia5Mm","40010473","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3216.42","3216.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Art L110Cm L60Mm Dia5Mm","40010474","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 5Fr L45Cm Hydrphlc","40010475","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","233.04","233.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L145Cm Dia0.035In","40010476","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","561.96","561.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microcath Infus 2.4Fr L150Cm","40010477","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","735.9","735.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5Fr L135Cm D0.038X0.029In","40010478","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1386.1","1386.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L190Cm Dia0.012/0.014In","40010479","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire L190Cm Dia0.011/0.014In","40010480","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Microintroducer L7Cm Cath 5Fr","40010481","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","706.46","706.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L80Mm Dia6Mm Cath","40010482","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2299.59","2299.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L100Mm D5.0Mm","40010483","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L60Mm Dia9Mm","40010484","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","3256.5","3256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Pericardcent 8.3Fr Pgtl","40010485","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 9Fr L10Cm Mini","40010486","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","231.92","231.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L75Cm L40Mm Dia8Mm","40010487","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2839","2839","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L60Mm Dia10Mm","40010488","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia6Mm","40010489","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L120Cm L20Mm Dia16Mm","40010490","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","468.72","468.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L120Cm L20Mm Dia14Mm","40010491","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","468.72","468.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L20Mm Dia5Mm","40010492","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L200Cm L120Mm D1.5Mm","40010493","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","334.5","334.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L20Mm Dia2Mm","40010494","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L40Mm Dia2Mm","40010495","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","385.79","385.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia3.5Mm","40010496","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia3Mm","40010497","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L143Cm L6Mm Dia2Mm","40010498","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","1586.5","1586.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L20Mm Dia3Mm","40010499","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","468.3","468.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L40Mm Dia6Mm","40010500","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L60Mm Dia14Mm","40010501","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4Fr L135Cm L60Mm Dia6Mm","40010502","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4Fr L135Cm L60Mm Dia5Mm","40010503","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","324.47","324.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L150Cm L210Mm Dia3X2.5Mm","40010504","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","822.87","822.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L135Cm L20Mm Dia5Mm","40010505","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","238.61","238.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L150Cm L60Mm Dia4Mm","40010506","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","245.3","245.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 525Cc Dia13.9Cm","40010507","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2.5Mm Sft Tiss","40010508","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","782.73","782.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L30Mm Dia8Mm","40010509","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L40Mm Dia7Mm","40010510","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiberoptix(Tm) Iab","40010511","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2262.85","2262.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 3Mm X 15Mm Cor","40010512","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","7853.5","7853.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L80Cm L30Mm Dia7Mm","40010513","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","780.5","780.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fiberoptix(Tm) Iab B","40010514","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2262.85","2262.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Sternal H-Plate Sm 8 H","40010515","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1357.38","1357.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Support","40010516","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","23214.29","23214.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amvia Edge Dr-T","40010517","CDM","275","RC","C1785","HCPCS","","","facility","both","","","","5893.6","5893.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Support For Vascular","40010518","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","23214.29","23214.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Support For Vascular","40010519","CDM","278","RC","C8000","HCPCS","","","facility","both","","","","23214.29","23214.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frontier 2Mmx30Mm Zotarolimus","40010520","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1112.77","1112.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Swivelock Sp Bc Kl 4.75Mm","40010523","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1103.85","1103.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spinal Med 11 Deg 10Mm","40010524","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","20155","20155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl Alif M 0 Deg 10Mm","40010525","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","20155","20155","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide 6Fr L55Cm Dia0.07In","40010526","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","193.4","193.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia3Mm Orsiro","40010527","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 8Fr L55Cm Dia2.9Mm","40010528","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","167.25","167.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L400Mm Dia10Mm R Fem","40010529","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2971.03","2971.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Bplr Od55Mm Id28Mm Fem","40010530","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","964.59","964.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia2.5Mm Orsir","40010531","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 5.8Fr L180Cm L4Cm Dia4Mm","40010532","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","501.77","501.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X55Mm Cann","40010533","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","448.23","448.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia3.5Mm Orsir","40010534","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia3Mm Co Ally","40010535","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L150Mm Dia6Mm Cath","40010536","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5872.75","5872.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Infus 5Fr 50X35Cm Prss","40010537","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","740.36","740.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L27Mm Dia7Mm Cath","40010538","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Dil Sm 12Fr L43Cm","40010539","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","635.55","635.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L145Cm Dia0.035In","40010540","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","550.72","550.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia3Mm Co Ally","40010541","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Onyx Dia4Mm L22Mm Zotarolimus","40010542","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","876.75","876.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Paracent D19Ga Cath L10Cm","40010543","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","63.36","63.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 6.0Mm X 150Mm 6Fr X120Cm","40010544","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"3Mm Dia0.035In Poly Std Sl Str","40010545","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","103.09","103.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L35Mm Dia2.5Mm Orsir","40010546","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L40Mm Dia3Mm Orsiro","40010547","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X38Mm Canc Hex Hd","40010548","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 6Fr L180Cm 54-57-60Fr","40010549","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","366.12","366.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L40Mm Dia5.5Mm Cath 6Fr","40010550","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","2299.59","2299.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mic 2.5X2.8X10Mm Com","40010551","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1657.26","1657.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mic 2.5X2.8X8Mm Comp","40010552","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","403.63","403.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L54Mm Dia4.5Mm Ns","40010553","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","365.05","365.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mic 2.8X20Mm Calcnl","40010554","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mic 2.8X13Mm Calcnl","40010555","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mic 2.5X2.8X12Mm Com","40010556","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia2.5Mm Orsir","40010557","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath 7Fr L25Cm Dil L2.5Cm","40010558","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","529.63","529.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Morcellator Hysteroscopic Mini","40010559","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl 18Ga L60Cm Thrw L20Cm Shth","40010560","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","1039.16","1039.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Supp Ad Ped 4Fr L90Cm","40010561","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1115","1115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shth 9X17Fr L13.6Cm Ctrl Rot","40010562","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","2580.15","2580.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L150Cm Dia0.025In","40010563","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","44.59","44.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L8Mm Dia2Mm Co Plat","40010564","CDM","278","RC","C1894","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Canc Cann Ln","40010565","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Nephstmy 24Fr L35Cm Incl","40010566","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","240.3","240.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Picc Neo Ped 1.9Fr L50Cm","40010567","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","695.92","695.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2Mm Co Plat","40010568","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L37Mm Dia7Mm Il","40010569","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1099.91","1099.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne Mic 2.5X2.8X24Mm Com","40010570","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Defib Card 3 Chmbr 2 Df1 Is4","40010571","CDM","275","RC","C1882","HCPCS","","","facility","both","","","","5838","5838","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Periph L80Mm Dia5.5Mm 6Fr","40010572","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1914.03","1914.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Tib Dia18Mm Plsm Base Cem","40010573","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1805.27","1805.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blade Im L95Mm Dia10.35Mm Prox","40010574","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1013.36","1013.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X56Mm Canc Cann","40010575","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.5X12Mm Compr Ft Hd","40010576","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","530.74","530.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"1.1Mm K-Wire","40010577","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","118.58","118.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 7.5X55Mm","40010578","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crossconnector Spnl L43-55Mm","40010579","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2620.23","2620.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem 22.2Mm X 3Mm Ceramic","40010580","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit Unknown Size","40010581","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1799.32","1799.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pump Ith 87.5Mm Thck 19.6Mm","40010582","CDM","278","RC","C1772","HCPCS","","","facility","both","","","","23796.8","23796.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Strnl Star 6H Mtrx Strnm","40010583","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1302.6","1302.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Strnl Sq Plt Sm 4 H Mtrx","40010584","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1269.2","1269.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib R 6 H St 118Mm","40010585","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1578.23","1578.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0 V Tm Db Ao Qc 115Mm 30Mm","40010586","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","377.49","377.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Sacroiliac 9.5Mmx90Mm","40010587","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5073.5","5073.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Spnl Nit Shrp","40010588","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","139.5","139.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl W16Xh6Xl14Mm 13Deg","40010589","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3256.5","3256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Spnl L42Mm Ant Cerv","40010590","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Cortex 4.5Mmx64Mm Self Tap","40010591","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","52.28","52.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X66Mm Cort Hex","40010592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","52.28","52.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X26Mm Canc Hex Hd","40010593","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","766.32","766.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X24Mm Canc Hex Drv","40010594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Lag Dhs Dcs 12.7Mmx125Mm","40010595","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","599.62","599.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Hum R 4 H 122Mm","40010596","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1651.63","1651.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Pat Ant Sm 6 H St Ss","40010597","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3476.11","3476.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Pedcl 5.5X50Mm","40010598","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl Thorlum 5.5X110Mm","40010599","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Pedcl 5.5X35Mm","40010600","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Lcp Recon 3.5Mm 8H 112Mm","40010601","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1040.14","1040.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X45Mm Canc Hex Hd","40010602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Fib Lat R 5 H 99Mm","40010603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","877.65","877.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 1.5X3Mm Cmf Ft Self","40010604","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1680.27","1680.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphintom 4.4Fr Cut Wire L30Mm","40010605","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","896.15","896.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L180Cm Dia0.014In","40010606","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","312.2","312.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca L130Cm L80Mm Dia4Mm","40010607","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","1878.75","1878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L26Cm Percflx","40010608","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","316.66","316.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm Dia3Mm Orsiro","40010609","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm Dia8Mm Cath","40010610","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm Dia2.5Mm Orsiro","40010611","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introducer Shth 7Fr L4Cm Sht","40010612","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","156.1","156.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar L150Mm Dia7Mm Cath","40010613","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5872.75","5872.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent L59Cm Dia8Cm Cath L120Cm","40010614","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3857.25","3857.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm D2.25Mm Orsiro","40010615","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr L100Cm Id0.07In","40010616","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Genrtr Chrg Remot Hfx Iq Ipg","40010617","CDM","278","RC","C1822","HCPCS","","","facility","both","","","","37530","37530","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cor Intvnt Xb3 6Frx 100Cm","40010618","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 3 Thk9Mm Knee X3","40010619","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 3 R Knee","40010620","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Pat Sz 40 Thk11Mm","40010621","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1336","1336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 8 L Knee Cr","40010622","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Tib Sz 8 Thk11Mm Knee","40010623","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1670","1670","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Sz 8 Ap60Mm Ml85","40010624","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X180Mm Canc Hex","40010625","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","281.05","281.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr L100Cm Tip","40010626","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Intvent Xb4 6Fr X 100Cm","40010627","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Invnt Xb3.5 2Sh 6Frx100Cm","40010628","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Intvent Xb3.5 7Fr X 100Cm","40010629","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum R 4 H St 122Mm","40010630","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1842.56","1842.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Dst Lat 7H 125Mm","40010631","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1402.8","1402.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 5 H Broad Y Plt Ti","40010632","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2753","2753","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X26Mm T10 Drv Ft","40010633","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.91","259.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X28Mm T10 Drv Ft","40010634","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.91","259.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X34Mm T10 Drv Ft","40010635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.91","259.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X44Mm T10 Drv Ft","40010636","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.91","259.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X10Mm Canc Hex Drv","40010637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","43.83","43.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.4Mm V Tm Cort Scr 18Mm T8","40010638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.99","237.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.7Mm V Tm Cort Scr 60Mm T8","40010639","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","237.99","237.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"60Mm Depth Probe","40010640","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","4676","4676","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X80Mm Cort Hex","40010641","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","90.93","90.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 13Mm R Fix Bear Med Cong","40010642","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 7.5Mm X 55Mm Masada","40010643","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tulip Spinal Ti6Al4Veli Masada","40010644","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrw Spnl Tulip T30 Tall Masad","40010645","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L55Mm Od5.5Mm Ticp","40010646","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl 7.5Mm X 60Mm Masada","40010647","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1503","1503","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spnl L80Mm Od5.5Mm Ticp","40010648","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","557.5","557.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 5 R Knee","40010649","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2919","2919","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh W10Xl20Cm Thk1.6Mm 6Mm","40010650","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","6672","6672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 3X8 H T Plt 97Mm R A","40010651","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","926.47","926.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 2.7X44Mm Cort Hex","40010652","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","55.72","55.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.3X160Mm Canc Hex","40010653","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","501.75","501.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"8-11 11Mm R Fix Bear Med Cong","40010654","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem Sz 4 Std L Cr","40010655","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3502.8","3502.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"H16Mm L Vivacit-E Polyeth Med","40010656","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ank 3Cc 15Gax60Mm End Del","40010657","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6074.3","6074.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 7 H 1/3 Tblr 83Mm Ti","40010658","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","791.43","791.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss L Talar Asep","40010659","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","9521.5","9521.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4.5X20Mm Cort Hex","40010660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","56.3","56.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilapan-S 4 X 65Mm","40010661","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","189.72","189.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilapan-S 4 X 55Mm","40010662","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","151.64","151.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph 16Mm X 120Mm Abre","40010663","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3131.25","3131.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X16Mm Unicortical","40010664","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","338.74","338.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa 16Mmx20Mmx93Mm","40010665","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6571.92","6571.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa 16Mmx16Mmx93Mm","40010666","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","6204.96","6204.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endcap Orth 5Mm Ti Ally Xl25","40010667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","476.6","476.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Evar Aaa 32Mmx14Mmx130Mm","40010668","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","13310.64","13310.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X28Mm Cort Ft","40010669","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","130.71","130.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X20Mm Cort Ft","40010670","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","130.71","130.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Fix L190Mm Dia6Mm Ss Spd","40010671","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","149.15","149.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X36Mm Calcnl Cor","40010672","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X34Mm Calcnl Cor","40010673","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X40Mm Calcnl Cor","40010674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X28Mm Calcnl Cor","40010675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.95","367.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 5X80Mm Thrd Conic Hd","40010676","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","270.05","270.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X130Mm Cort Hex","40010677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","203.11","203.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X20Mm Canc Hex Hd","40010678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 4X10Mm Canc Hex Drv","40010679","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Cort Ft St","40010680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.42","77.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X42Mm Ft Cort Ft","40010681","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X44Mm Canc Cann Ln","40010682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","364.92","364.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X16Mm Compr Cann","40010683","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","744.82","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3X14Mm Compr Cann","40010684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","744.82","744.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X12Mm Ank Cort","40010685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","125.55","125.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3Di L12 Mm Od3.5 Mm","40010686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","443.77","443.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X18Mm Ank Cort","40010687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","818.41","818.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L58Mm Dia2.7Mm","40010688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113.55","113.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X22Mm Cort Ft","40010689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","77.42","77.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mini 3.6X24Mm Calcn","40010690","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","991.98","991.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 6.5X80Mm Canc Hex","40010691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.68","480.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Ti L10 Mm Od2.3 Mm","40010692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","256.45","256.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Lcp Ss L40 Mm Od4Mm","40010693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","48.73","48.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 1.5X14Mm Cort T4","40010694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","100.58","100.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 2.7X14Mm Ank Cort","40010695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","125.55","125.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X22Mm Cort Ft","40010696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.87","229.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X10Mm Canc Hex Hd","40010697","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X12Mm Canc Hex Hd","40010698","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","51.17","51.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X50Mm Cort Ft","40010699","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.87","229.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 4X46Mm Compr Cann","40010700","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","945.52","945.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X46Mm Stardrv Rcs","40010701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","229.87","229.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl 7Deg 6Mmx18Mmx16Mm","40010702","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4170","4170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 3.5X30Mm Stardrive","40010703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rod Spinal Pt Specific Ti 6Mm","40010704","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","2672","2672","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5 Hole 2Mm X 29Mm","40010705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1225.28","1225.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Volt Tm Cort Scr 20Mm T6","40010706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","262.6","262.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Volt Tm Lock Scr 18Mm T6","40010707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.07","480.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"2.0Mm Volt Tm Lock Scr 26Mm T6","40010708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","480.07","480.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ct Limited/Follow Up Study","40010709","CDM","350","RC","76380","HCPCS","","","facility","both","","","","2011","2011","","","","","","","","","","","","","Gross Charge Type: Standard"
"3D Render W/Intrp Postprocess","40010710","CDM","350","RC","76377","HCPCS","","","facility","both","","","","2097","2097","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Post Pedcl 8.5X50Mm","40010711","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2505","2505","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt 4Mmx16Mm Synergy Megatron","40010712","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2004","2004","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crosslink Spnl Xl Hd To Hd Var","40010713","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1795.25","1795.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl W18Xh8Xl15Mm 13Deg","40010714","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3256.5","3256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacer Spnl W18Xh7Xl15Mm 13Deg","40010715","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","3256.5","3256.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Spnl 3.5/4X15Mm Post","40010716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1795.25","1795.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3.5X10Mm T10 Drv Ft","40010717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","259.91","259.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Fib Dst Lat 6H 113Mm","40010718","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1292.33","1292.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"High Angulation Plt 1-Lev 12Mm","40010719","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1419.5","1419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"3D Por Ti Crv 16X14Mm 9Mm Ht 6","40010720","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","4517.5","4517.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 4.0 Len 16 Mm St","40010721","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","278.75","278.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph Ven 18Mm X 120Mm","40010722","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3131.25","3131.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili 10Fr Barb To Barb","40010723","CDM","278","RC","C2625","HCPCS","","","facility","both","","","","301.05","301.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Hum L 2 H St M 82Mm","40010724","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1912.53","1912.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X28Mm Stardrv Reces","40010725","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 3X20Mm Stardrv Reces","40010726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","762.44","762.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X26Mm Hindfoot Cor","40010727","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","250.74","250.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infus Prt 8Fr Grosh Vlv Intmed","40010728","CDM","278","RC","C1788","HCPCS","","","facility","both","","","","646.7","646.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Inside Dia0.07In","40010729","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia4.5Mm Co","40010730","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia2.25Mm Orsi","40010731","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia4.5Mm Co","40010732","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent 4.50Mm Dx30Mm Stnt 3.2Fr","40010733","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Brst Bx 15Ga Ti Btrfly","40010734","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","215.04","215.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth 14Fr L30Cm Id4.6Mm","40010735","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","294.54","294.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia2.25Mm Orsi","40010736","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","20.78","20.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Marker Brst Bx 15Ga Ti Opn Coi","40010737","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","215.04","215.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Iv 20Ga L2.25In Accucath","40010738","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","133.92","133.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr D0.07In Amplatz","40010739","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L380Mm Dia9Mm L Fem","40010740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3104.53","3104.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 8 H Nar 152Mm Ss Lcp","40010741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","958.57","958.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ld No2 L65Cm Dia0.017 0.026In","40010742","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","3014.35","3014.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Sys 2.75Mm X 40Mm Orsiro","40010743","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr L100Cm 0.088In","40010744","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 8Fr L100Cm Tp L0.1In","40010745","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone Sm Calcnl Polyax Pe","40010746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3104.98","3104.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cv 6Fr 2 Lumn Polyur","40010747","CDM","272","RC","C1751","HCPCS","","","facility","both","","","","897.22","897.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm Dia3.5Mm Orsiro","40010748","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Dia0.07In Hockst","40010749","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm D2.75Mm Orsiro","40010750","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1169","1169","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Dia0.07In Judkin","40010751","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L345Mm Dia11Mm Univ Lt","40010752","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1608.33","1608.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L15Mm Dia2Mm Co Plat","40010753","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ad 7Fr L55Cm Dia0.081In","40010754","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","193.4","193.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia2.5Mm Co","40010755","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L13Mm D2.75Mm Orsiro","40010756","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L150Cm Dia0.035In","40010757","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","112.52","112.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"6-7 H14Mm L Med Cong Fix Bear","40010758","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2282.19","2282.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumimark Breast Biopsy St Mrkr","40010759","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1331.83","1331.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mrkr Breast Biopsy 15Ga Tulip","40010760","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","1331.83","1331.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mrkr Brst Bx Site Ti Dragonfly","40010761","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","230.94","230.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Tiss Rem Hysteroscopic","40010762","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","1850.91","1850.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L60Mm Dia8Mm Cath","40010763","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 4Fr X 110Cm Acc","40010764","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","350.2","350.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Trachbronch L22Mm Dia7Mm","40010765","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","250.43","250.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L65Cm Gwire","40010766","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","710.14","710.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm D2.75Mm Orsiro","40010767","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L100Cm Gwire","40010768","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","592.96","592.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Angio 5Fr L100Cm Gldewire","40010769","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","592.96","592.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia4Mm Co Ally","40010770","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L150Cm Dia0.035In","40010771","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","170.8","170.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss W3Xl4Cm Plcnta","40010772","CDM","278","RC","Q4133","HCPCS","","","facility","both","","","","2096.69","2096.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne R Sup Dst Clav 13 H","40010773","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2252.83","2252.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia3Mm Co Ally","40010774","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 1St Mt Fus R Md 6 H","40010775","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3380.48","3380.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sterile 4F System 150Cm","40010776","CDM","","","","","","","facility","both","","","","3747","3747","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stpl W20Xl30Mm Bone Fix Brdg","40010777","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1553.94","1553.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia4Mm Co Ally","40010778","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"L150Cm Uret Blln L2Cm Spindle","40010779","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","800.3","800.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath 4Mmx4Cm Tip L4Cm Passprt","40010780","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","704.26","704.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia3Mm Co Ally","40010781","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2.5Mm Orsir","40010782","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide 6Fr L90Cm Im Crv Pt","40010783","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath L4.75In Dia8Fr Ndl L8In","40010784","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","56.3","56.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide 7Fr L100Cm R Cor","40010785","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Inside Dia0.07In","40010786","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Intro 12Fr L91.4Cm Fem","40010787","CDM","272","RC","C1893","HCPCS","","","facility","both","","","","501","501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 8Fr L70Cm Dia2.9Mm","40010788","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","212.74","212.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 8Fr L55Cm Dia2.9Mm","40010789","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","189.1","189.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Bili L19Mm Dia7Mm Cath","40010790","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","1461.25","1461.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L180Cm Dia0.035In","40010791","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","78.12","78.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth 7Fr L70Cm Id2.5Mm","40010792","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","212.74","212.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 10Cc Vi Dia4.8Mm","40010793","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","871.93","871.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Im L440Mm Dia2.5Mm Prox","40010794","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","607.68","607.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fix L14Mm Rnd 2Pc","40010795","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2483.29","2483.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guide Ad 7Fr L100Cm Cor","40010796","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L36Mm 4 H Bilat Ss","40010797","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","729.86","729.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Ptca 7Fr L80Cm Blln L40Mm","40010798","CDM","272","RC","C2623","HCPCS","","","facility","both","","","","2329.65","2329.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Occl L150Cm Mic 90Deg","40010799","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1085.5","1085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia3.5Mm Co","40010800","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.5Mm Co","40010801","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge 12Fr L25Cm Trcr 17G","40010802","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","896.79","896.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Emb 4Fr L40Cm Blln Dia9Mm","40010803","CDM","272","RC","C1757","HCPCS","","","facility","both","","","","1002.72","1002.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Dil 5Fr X 180Cm Blln 6Mm","40010804","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","493.01","493.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vasc 6Mm X 60Cm Eptfe","40010805","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","2705.4","2705.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Es L10Cm Dia23Mm Cath","40010806","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2936.32","2936.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Vasc 10Fr L13Cm 0.038In","40010807","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","169.77","169.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Cath 7Fr L55Cm 0.018In","40010808","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","180.63","180.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L40Mm Dia9Mm Cath","40010809","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","864.23","864.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2.5Mm Co","40010810","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Guid 7Fr L90Cm Dia2.5Mm","40010811","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","348.53","348.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne Rad Dphseal Mtphseal","40010812","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2120.08","2120.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone 5X14Mm Dst Fem Cort","40010813","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","405.1","405.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone L40Mm 4 H Bilat Ss","40010814","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","770.04","770.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph L19Mm Dia7X11Mm","40010815","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","4026.83","4026.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hern Xl W22.1Xl27.1Cm","40010816","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3024.37","3024.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge L250Cm Od6Fr Gwire","40010817","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","289.9","289.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Supp L65Cm Dia0.018In","40010818","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","522.6","522.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Infus 5Fr L135Cm Slt Pat","40010819","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","925.45","925.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr L100Cm Dil 0.07I","40010820","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","167.4","167.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Nephstmy L26Cm Cath","40010821","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","288","288","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L9Mm Dia2.5Mm Cath","40010822","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L13Mm Dia2.5Mm Cath","40010823","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","892","892","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Periph 6Fr L40Mm Gwire","40010824","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1962.25","1962.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 7Fr L55Cm Dia0.081In","40010825","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","193.4","193.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Endopros L2.5Cm Dia6Mm","40010826","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","5019.29","5019.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia5Mm Co Plat","40010827","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 7Fr L55Cm Dia0.081In","40010828","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","193.4","193.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Shth 6Fr L10Cm Ndl 22Ga","40010829","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","198.92","198.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia2.25Mm Co","40010830","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreas L8Cm Od10Fr","40010831","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","192.58","192.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stylet Lok L140Cm Act L70Cm","40010832","CDM","272","RC","C1773","HCPCS","","","facility","both","","","","1085.5","1085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Fem Od36Mm +0Mm Offset","40010833","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1360.22","1360.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L24Mm Dia3Mm 16Atm","40010834","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1837","1837","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Endscp L260Cm Dia0.035In","40010835","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","655.13","655.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Drnge 8.5Fr L40Cm Seg L","40010836","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","226.26","226.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm D2.25Mm Orsiro","40010837","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Uret 8Fr L26Cm Flexima","40010838","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","267.6","267.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2Mm Co Plat","40010839","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Dil 6Fr L180Cm Blln","40010840","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","366.12","366.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L12Mm Dia3Mm Co Ally","40010841","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L30Mm Dia2.25Mm Co","40010842","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1252.5","1252.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L22Mm Dia2Mm Co Plat","40010843","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L18Mm Dia5Mm Co Plat","40010844","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","1377.75","1377.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Guid 6Fr Dia0.07In Mp 1","40010845","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","153.45","153.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gwire Vasc L190Cm Dia0.014In","40010846","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","334.8","334.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Pace 7.2Fr L35Cm Epicard","40010847","CDM","278","RC","C1896","HCPCS","","","facility","both","","","","1661.65","1661.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mic 2.8X18Mm Calcnl","40010848","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1324.62","1324.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone Mic 2.8X30Mm Calcnl","40010849","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1324.62","1324.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"W1-2Xl3.5-4Cm Thk1.8-2.2Mm","40010850","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1116.68","1116.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead Icd L65/15Cm Rv And Atr","40010851","CDM","275","RC","C1777","HCPCS","","","facility","both","","","","4051.85","4051.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endomet Ablat Comb Imped Ctrl","40010852","CDM","272","RC","C1886","HCPCS","","","facility","both","","","","2031.82","2031.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne 7.5X80Mm Compr Hdlss","40010853","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1079.02","1079.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spacr Spnl 20Deg 7Mmx12Mmx25Mm","40010854","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","9035","9035","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Spnl Fen Cann 6.5Mmx55Mm","40010855","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1283.66","1283.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L26Mm Dia3Mm Orsiro","40010856","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L13Mm Dia3.5Mm Orsir","40010857","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L35Mm Dia3.5Mm Orsir","40010858","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","329.34","329.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Diag L150Cm Dia0.025In","40010859","CDM","272","RC","C1887","HCPCS","","","facility","both","","","","1085.5","1085.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Cor L40Mm Dia4Mm Orsiro","40010860","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","918.5","918.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stnt Uret 7Fr L26Cm Hydr+ Coat","40010861","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","356.49","356.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tool Legend 9Cm X 30Mm Mh","40017667","CDM","272","RC","","","","","facility","both","","","","623.44","623.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shealth Station Sphere 1 Pk","40017668","CDM","272","RC","","","","","facility","both","","","","1154.08","1154.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shealth Station Sphere 4 Pk","40017669","CDM","272","RC","","","","","facility","both","","","","1238.3","1238.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40017670","CDM","272","RC","","","","","facility","both","","","","1357.13","1357.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Passive Trajectory Guide","40017671","CDM","278","RC","","","","","facility","both","","","","2050.98","2050.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Axiem Cranial Tracer Pointer","40017673","CDM","272","RC","","","","","facility","both","","","","6067","6067","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Infuse 1.4Cc Xs","40017674","CDM","278","RC","","","","","facility","both","","","","6625.12","6625.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Infuse Lg L26Mm","40017676","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","12776","12776","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemostat Vitagel 4.5Ml","40017677","CDM","272","RC","","","","","facility","both","","","","1964.81","1964.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Ventralight 25X33","40017680","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4296.88","4296.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Jejunal Feeding Tube 16Fr","40017684","CDM","270","RC","","","","","facility","both","","","","354.22","354.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Savory Guide Wire","40017685","CDM","270","RC","","","","","facility","both","","","","331.12","331.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Colonic Wallflex Nitinol","40017686","CDM","278","RC","C1876","HCPCS","","","facility","both","","","","3929.3","3929.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.531 Synthes 1.6Mm Screw","40017687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.532 Synthes  1.6Mm Screw","40017688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.533 Synthes 1.6Mm Screw","40017689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"200.534 Synthes 1.6Mm Screw","40017690","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204.48","204.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.214.112 Synthes Lcp","40017691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","146.25","146.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.322 Synthes Screw","40017692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","392.7","392.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.257 Synthes Plate","40017693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1032.55","1032.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.259 Synthes Plate","40017694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1032.55","1032.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle -  Endoscopic Echotip U","40017695","CDM","270","RC","","","","","facility","both","","","","341.25","341.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompression Kit Marcon .","40017696","CDM","270","RC","","","","","facility","both","","","","329.6","329.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pancreatic Zimmon Polyet","40017697","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","175","175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endoscopic Direct","40017698","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","349.13","349.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endoscopic Jagwire S","40017699","CDM","270","RC","C1769","HCPCS","","","facility","both","","","","312.64","312.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eus Balloon","40017700","CDM","270","RC","","","","","facility","both","","","","66.81","66.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Ventralight 10X 15","40017701","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1924.06","1924.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Ventralight 15X20","40017702","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","2452.69","2452.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Ventralight 20X25","40017703","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3527.35","3527.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.680 Synthes Lcp Plate","40017704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1257.9","1257.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"241.681 Synthes Lcp Plate","40017705","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1257.9","1257.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.240.065 Synthes 3.7Mm Screw","40017706","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.16","546.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.240.085 Synthes 3.7Mm Screw","40017707","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","546.16","546.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.267 Synthes 1.5 Fractur","40017708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1516.81","1516.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"02.130.004 Synthes Screw","40017709","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","154.06","154.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter - Embolectomy 3Fr 40C","40017710","CDM","272","RC","","","","","facility","both","","","","174.72","174.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Small Joint Suture Tak Disp In","40017711","CDM","272","RC","","","","","facility","both","","","","387.35","387.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"351.706S Synthes Sterile Reame","40017714","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1890.75","1890.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Angiotensin Converting Enzyme,","40017715","CDM","301","RC","82164","HCPCS","","","facility","both","","","90","28","28","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 90: Reference (Outside) Laboratory"
"Screw Bne L18Mm Dia5Mm Cort Ti","40017716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","381.49","381.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cont Intraop Neurophys Mon/Hr","40055552","CDM","360","RC","95940","HCPCS","","","facility","both","","","","914","914","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunoassay Nonantibody","40080738","CDM","301","RC","83516","HCPCS","","","facility","both","","","90","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 90: Reference (Outside) Laboratory"
"Assay Iga/Igd/Igg/Igm Each","40080739","CDM","301","RC","82784","HCPCS","","","facility","both","","","90","7","7","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 90: Reference (Outside) Laboratory"
"Sars Cov2 Rna (Covid-19) Qinaa","40081009","CDM","306","RC","87635","HCPCS","","","facility","both","","","90","68","68","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 90: Reference (Outside) Laboratory"
"Sars-Cov-2 Ab (Igg), Ia","40081010","CDM","302","RC","86769","HCPCS","","","facility","both","","","90","65","65","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 90: Reference (Outside) Laboratory"
"Panalock Anchor-(210130)","40086696","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","7728.5","7728.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim No Prog","40101030","CDM","983","RC","95970","HCPCS","","","facility","both","","","","56.27","56.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Paravert F Jnt C/T 2 Le","40101033","CDM","983","RC","64491","HCPCS","","","facility","both","","","","292.71","292.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Paravert F Jnt C/T 3 Le","40101034","CDM","983","RC","64492","HCPCS","","","facility","both","","","","295.1","295.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Paravert F Jnt L/S 1 Le","40101035","CDM","983","RC","64493","HCPCS","","","facility","both","","","","547.55","547.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Paravert F Jnt L/S 2 Le","40101036","CDM","983","RC","64494","HCPCS","","","facility","both","","","","274.77","274.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Paravert F Jnt L/S 3 Lev","40101037","CDM","983","RC","64495","HCPCS","","","facility","both","","","","274.77","274.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Localization By Xray","40101038","CDM","983","RC","77002","HCPCS","","","facility","both","","","","349.92","349.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroguide For Spine Inject","40101039","CDM","983","RC","77003","HCPCS","","","facility","both","","","26","324.84","324.84","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Pf Inj Paravert F Jnt C/T 1 Le","40101041","CDM","983","RC","64490","HCPCS","","","facility","both","","","","596.19","596.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Cerebro Spinal Fluid - 6","40101043","CDM","983","RC","62272","HCPCS","","","facility","both","","","","566.91","566.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 1-2 Studies","40101067","CDM","983","RC","95907","HCPCS","","","facility","both","","","","298.46","298.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 3-4 Studies","40101068","CDM","983","RC","95908","HCPCS","","","facility","both","","","","380.46","380.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 5-6 Studies","40101069","CDM","983","RC","95909","HCPCS","","","facility","both","","","","455.75","455.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 7-8 Studies","40101070","CDM","983","RC","95910","HCPCS","","","facility","both","","","","598.43","598.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 9-10 Studies","40101071","CDM","983","RC","95911","HCPCS","","","facility","both","","","","715.85","715.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction 11-12 Studies","40101072","CDM","983","RC","95912","HCPCS","","","facility","both","","","","815.58","815.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Conduction => 13 Studies","40101074","CDM","983","RC","95913","HCPCS","","","facility","both","","","","942.24","942.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"2Nd Opinion Consultation","40101082","CDM","983","RC","","","","","facility","both","","","","654.81","654.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Record Reveiw 30-60 Minutes","40101084","CDM","983","RC","","","","","facility","both","","","","98.22","98.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Team Conference 30 Minutes","40101086","CDM","983","RC","","","","","facility","both","","","","287.65","287.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intermediate Phone Call","40101090","CDM","983","RC","","","","","facility","both","","","","210.48","210.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lengthy Phone Call","40101092","CDM","983","RC","","","","","facility","both","","","","245.55","245.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","40101206","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","40101210","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","40101214","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","40101222","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","40101230","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv 1 Extremity 1-4","40101240","CDM","983","RC","64642","HCPCS","","","facility","both","","","","440.38","440.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv 1 Extrem 1-4 Ea","40101241","CDM","983","RC","64643","HCPCS","","","facility","both","","","","275.01","275.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv 1 Extrem 5/> Mus","40101242","CDM","983","RC","64644","HCPCS","","","facility","both","","","","518.93","518.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv 1 Extrem 5/> Ea","40101243","CDM","983","RC","64645","HCPCS","","","facility","both","","","","350.64","350.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Trunk Musc 1-5","40101244","CDM","983","RC","64646","HCPCS","","","facility","both","","","","441.61","441.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Trunk Musc 6/>","40101245","CDM","983","RC","64647","HCPCS","","","facility","both","","","","522.86","522.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenerv Musc Neck Dyston","40101246","CDM","983","RC","64616","HCPCS","","","facility","both","","","","389.08","389.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","40101313","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","40101321","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","40101339","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","40101347","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged Svcs W/O Contact","40101398","CDM","983","RC","99358","HCPCS","","","facility","both","","","","323.32","323.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Sheath","40101404","CDM","983","RC","20550","HCPCS","","","facility","both","","","","164.16","164.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Major Joint W/O Us","40101438","CDM","983","RC","20610","HCPCS","","","facility","both","","","","186.17","186.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis Small Joint","40101495","CDM","983","RC","20600","HCPCS","","","facility","both","","","","151.67","151.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","40101503","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","40101545","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","40101560","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","40101586","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","40101859","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Origin","40101875","CDM","983","RC","20551","HCPCS","","","facility","both","","","","168.92","168.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1-2 Muscles","40101891","CDM","983","RC","20552","HCPCS","","","facility","both","","","","169.57","169.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Trigger Points 3/>","40101917","CDM","983","RC","20553","HCPCS","","","facility","both","","","","195.19","195.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wc Pr2 Or Return To Work","40101982","CDM","983","RC","","","","","facility","both","","","","32.74","32.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ballard Block Tray","40102022","CDM","272","RC","","","","","facility","both","","","","214.24","214.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pa Case Management - Brief","40102261","CDM","983","RC","","","","","facility","both","","","","173.06","173.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pa Case Management -Intermed","40102279","CDM","983","RC","","","","","facility","both","","","","210.48","210.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pa Case Management - Complex","40102287","CDM","983","RC","","","","","facility","both","","","","245.55","245.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Joint/Bursa W/O Us","40102295","CDM","983","RC","20605","HCPCS","","","facility","both","","","","157.23","157.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rf Cannula, Ea Needle","40102535","CDM","272","RC","A4210","HCPCS","","","facility","both","","","","93.73","93.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemodenervation Facial","40102626","CDM","983","RC","64612","HCPCS","","","facility","both","","","","407.04","407.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Test 1 Limb","40102683","CDM","983","RC","95860","HCPCS","","","facility","both","","","","381.62","381.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Test 2 Limbs","40102709","CDM","983","RC","95861","HCPCS","","","facility","both","","","","542.94","542.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg 2 Extremitities","40102717","CDM","983","RC","95861","HCPCS","","","facility","both","","","","542.94","542.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg 3 Exremities Pro Fee","40102725","CDM","983","RC","95863","HCPCS","","","facility","both","","","","673.41","673.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg 3 Extremities","40102733","CDM","922","RC","95863","HCPCS","","","facility","both","","","","606","606","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg 4 Extremities Pro Fee","40102741","CDM","983","RC","95864","HCPCS","","","facility","both","","","","795.5","795.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg 4 Extremities","40102758","CDM","922","RC","95864","HCPCS","","","facility","both","","","","716","716","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Cranial Nerve Unilat Pro F","40102766","CDM","983","RC","95867","HCPCS","","","facility","both","","","","343.32","343.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Cranial Nerve Unilateral","40102774","CDM","983","RC","95867","HCPCS","","","facility","both","","","","343.32","343.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Cranial Nerve Bilat Pro Fe","40102782","CDM","983","RC","95868","HCPCS","","","facility","both","","","","448.7","448.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Cranial Nerve Bilateral","40102790","CDM","983","RC","95868","HCPCS","","","facility","both","","","","448.7","448.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Thoracic Paraspinal Pro Fe","40102808","CDM","983","RC","95869","HCPCS","","","facility","both","","","","313.56","313.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Thoracic Paraspinal Muscle","40102816","CDM","922","RC","95869","HCPCS","","","facility","both","","","","282","282","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Limited Study Other Pro Fe","40102824","CDM","983","RC","95870","HCPCS","","","facility","both","","","","295.66","295.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Limited Study Other","40102832","CDM","922","RC","95870","HCPCS","","","facility","both","","","","266","266","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Fiber Elect W/ Qt Pro Fee","40102840","CDM","983","RC","95872","HCPCS","","","facility","both","","","","606.1","606.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emg Fiber Elect Qt Meas Ea Mus","40102857","CDM","922","RC","95872","HCPCS","","","facility","both","","","","545","545","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carpal Tunnel Tx Injection","40102923","CDM","983","RC","20526","HCPCS","","","facility","both","","","","237.45","237.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wc P And S","40102957","CDM","983","RC","","","","","facility","both","","","","438.68","438.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Anesthetic Ilioinguinal","40103053","CDM","983","RC","64425","HCPCS","","","facility","both","","","","352.05","352.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 1-2 Body Regions","40103079","CDM","983","RC","98925","HCPCS","","","facility","both","","","","94.58","94.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupuncture Wo Stim Init 15Min","40103194","CDM","983","RC","97810","HCPCS","","","facility","both","","","","120.44","120.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupuncture Wo Stim Ea Addl 15","40103202","CDM","983","RC","97811","HCPCS","","","facility","both","","","","90.6","90.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupuncture W/ Stim Init 15Min","40103210","CDM","983","RC","97813","HCPCS","","","facility","both","","","","128.55","128.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Acupuncture W/ Stim Ea Addl 15","40103228","CDM","983","RC","97814","HCPCS","","","facility","both","","","","103.06","103.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Intercost Mlt","40103293","CDM","983","RC","64421","HCPCS","","","facility","both","","","","101.82","101.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Cervicothoracic Inject","40103301","CDM","983","RC","22510","HCPCS","","","facility","both","","","","5964.49","5964.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Lumbosacral Injection","40103319","CDM","983","RC","22511","HCPCS","","","facility","both","","","","5920.18","5920.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Sacroiliac Joint","40103327","CDM","983","RC","27096","HCPCS","","","facility","both","","","","510.18","510.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Of Adhesions/Multi-1 Day","40103335","CDM","983","RC","62264","HCPCS","","","facility","both","","","","1372.19","1372.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percutaneous Diskectomy","40103343","CDM","983","RC","62287","HCPCS","","","facility","both","","","","1730.25","1730.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject For Spine Disk X-Ray","40103350","CDM","983","RC","62290","HCPCS","","","facility","both","","","","1120.69","1120.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Neuroelectrodes","40103384","CDM","983","RC","63650","HCPCS","","","facility","both","","","","6261.44","6261.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Anesth Occipital Nerve","40103400","CDM","983","RC","64405","HCPCS","","","facility","both","","","","212.25","212.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj,Intercost,Sngl","40103418","CDM","983","RC","64420","HCPCS","","","facility","both","","","","309.84","309.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Tfrm Epi C/T 1","40103459","CDM","983","RC","64479","HCPCS","","","facility","both","","","","803.16","803.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Tfrm Epi C/T Ea","40103467","CDM","983","RC","64480","HCPCS","","","facility","both","","","","397.34","397.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa&/Strd Tfrm Epi L/S 1","40103475","CDM","983","RC","64483","HCPCS","","","facility","both","","","","750.87","750.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Foramen Epidural Add-On","40103483","CDM","983","RC","64484","HCPCS","","","facility","both","","","","326.1","326.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block, Stellate Ganglion","40103491","CDM","983","RC","64510","HCPCS","","","facility","both","","","","438.24","438.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block, Lumbar/Thoracic","40103509","CDM","983","RC","64520","HCPCS","","","facility","both","","","","689.43","689.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Paravertebrl Nerve L/S","40103517","CDM","983","RC","64635","HCPCS","","","facility","both","","","","1305.99","1305.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Paravertebral N Ls Addon","40103525","CDM","983","RC","64636","HCPCS","","","facility","both","","","","549.23","549.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Cerv/Thor Facet Jnt","40103533","CDM","983","RC","64633","HCPCS","","","facility","both","","","","1318.81","1318.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Paravertebral N Ct Addon","40103541","CDM","983","RC","64634","HCPCS","","","facility","both","","","","601.28","601.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tx Othr Periperal Ne","40103558","CDM","983","RC","64640","HCPCS","","","facility","both","","","","787.41","787.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Complex","40103566","CDM","983","RC","95972","HCPCS","","","facility","both","","","","170.28","170.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"X-Ray Of Lower Spine Disk","40103590","CDM","983","RC","72295","HCPCS","","","facility","both","","","26","338.92","338.92","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Inj Aa/Strd Femoral Nrv W/Img","40103657","CDM","983","RC","64447","HCPCS","","","facility","both","","","","272.74","272.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tx Celiac Plexus","40103665","CDM","983","RC","64680","HCPCS","","","facility","both","","","","1065.69","1065.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj, Celiac Plexus","40103673","CDM","983","RC","64530","HCPCS","","","facility","both","","","","688.32","688.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stylet W/ Steering Cap","40103715","CDM","272","RC","","","","","facility","both","","","","451.14","451.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj, Suprascapular","40103830","CDM","983","RC","64418","HCPCS","","","facility","both","","","","257.4","257.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc/Repl Spine Nstim Pg/Rcvr","40103831","CDM","983","RC","63685","HCPCS","","","facility","both","","","","1055.18","1055.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Trigeminal","40103871","CDM","983","RC","64400","HCPCS","","","facility","both","","","","335.29","335.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Into Skin Lesions =<7","40103889","CDM","983","RC","11900","HCPCS","","","facility","both","","","","171.8","171.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Anesthetic Sciatic Nerv","40103905","CDM","983","RC","64445","HCPCS","","","facility","both","","","","398.87","398.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Absc Smpl Or Sgl","40103913","CDM","983","RC","10060","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Ext Eczema/Infect Skin","40103939","CDM","983","RC","11000","HCPCS","","","facility","both","","","","175.41","175.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrv Block,Other Peripheral","40103955","CDM","983","RC","64450","HCPCS","","","facility","both","","","","238.14","238.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb External Earn","40103997","CDM","983","RC","69200","HCPCS","","","facility","both","","","","251.76","251.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Brn Sm","40104013","CDM","983","RC","16020","HCPCS","","","facility","both","","","","257.76","257.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv 15-30Min","40104028","CDM","983","RC","G0396","HCPCS","","","facility","both","","","","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","40104029","CDM","983","RC","62270","HCPCS","","","facility","both","","","","436.93","436.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","40104030","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","40104031","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","40104032","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","40104033","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Spine Eltrd Perq Aray","40104034","CDM","983","RC","63663","HCPCS","","","facility","both","","","","2673.69","2673.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","40104035","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","40104036","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","40104037","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","40104038","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","40104042","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","40104043","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","40104044","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","40104045","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","40104047","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","40104048","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","40104049","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","40104050","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","40104051","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","40104052","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","40104053","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","40104054","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","40104055","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","40104056","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","40104057","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","40104058","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","40104059","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","40104060","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","40104061","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screening For Depression","40104062","CDM","983","RC","3725F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp <5 Yrs","40104063","CDM","983","RC","99151","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","40104064","CDM","983","RC","99152","HCPCS","","","facility","both","","","","164.03","164.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea","40104065","CDM","983","RC","99153","HCPCS","","","facility","both","","","","35.04","35.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp <5 Yrs","40104066","CDM","983","RC","99155","HCPCS","","","facility","both","","","","235.58","235.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp 5/>Yrs","40104067","CDM","983","RC","99156","HCPCS","","","facility","both","","","","220.09","220.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Ea","40104068","CDM","983","RC","99157","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Focused Hlth Risk Assmt","40104069","CDM","983","RC","96160","HCPCS","","","facility","both","","","","8.34","8.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caregiver Health Risk Assmt","40104070","CDM","983","RC","96161","HCPCS","","","facility","both","","","","8.34","8.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Potassium (K)","40104071","CDM","301","RC","84132","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Inj Interlaminar Crv/Thrc W Im","40104072","CDM","983","RC","62321","HCPCS","","","facility","both","","","","826.19","826.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Lmbr/Sac W Im","40104073","CDM","983","RC","62323","HCPCS","","","facility","both","","","","819.73","819.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Lmbr/Sac Wo I","40104074","CDM","983","RC","62322","HCPCS","","","facility","both","","","","466.72","466.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rev/Rem Impl Spinal Ns Receivr","40104075","CDM","983","RC","63688","HCPCS","","","facility","both","","","","1085.67","1085.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa/Strd Branch Plexus Img","40104076","CDM","983","RC","64415","HCPCS","","","facility","both","","","","348.47","348.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Needle Placement","40104077","CDM","983","RC","76942","HCPCS","","","facility","both","","","26","176.65","176.65","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Unlisted Proc Nervous System","40104078","CDM","983","RC","64999","HCPCS","","","facility","both","","","","585.81","585.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Neurolytic Intrcostl Nrv","40104080","CDM","983","RC","64620","HCPCS","","","facility","both","","","","631.37","631.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Brn Npgt Prgrmg 15 Min","40104081","CDM","983","RC","95983","HCPCS","","","facility","both","","","","148.97","148.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Brn Npgt Prgrmg Addl 15","40104082","CDM","983","RC","95984","HCPCS","","","facility","both","","","","130.91","130.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Simple","40104083","CDM","983","RC","95971","HCPCS","","","facility","both","","","","149.97","149.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wc P S Pr4 6 Pages","40104084","CDM","999","RC","","","","","facility","both","","","","394","394","","","","","","","","","","","","","Gross Charge Type: Standard"
"Quick Cup","40104085","CDM","983","RC","","","","","facility","both","","","","25.75","25.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Lum Spnl Puncture Fluor/Ct","40104086","CDM","983","RC","62328","HCPCS","","","facility","both","","","","829.92","829.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Spnl Puncture Csf Fluor/Ct","40104087","CDM","983","RC","62329","HCPCS","","","facility","both","","","","1023.36","1023.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Nrvs Si Jnt W Img","40104088","CDM","983","RC","64451","HCPCS","","","facility","both","","","","672.59","672.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Genclar Nrv Brnch","40104089","CDM","983","RC","64454","HCPCS","","","facility","both","","","","679.75","679.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dstrc Nurlyt Agt Genicular Nrv","40104090","CDM","983","RC","64624","HCPCS","","","facility","both","","","","1311.76","1311.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rf Ablt Nrv Innervtng Si W/Img","40104091","CDM","983","RC","64625","HCPCS","","","facility","both","","","","1594.32","1594.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Insert W/O Inj 1-2 Muscles","40104092","CDM","983","RC","20560","HCPCS","","","facility","both","","","","257.5","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ndl Insert W/O Inj 3+ Muscles","40104093","CDM","983","RC","20561","HCPCS","","","facility","both","","","","257.5","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","40104095","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","40104096","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","40104097","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","40104098","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","40104099","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","40104100","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","40104101","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","40104102","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","40104103","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","40104106","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","40104107","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","40104108","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","40104109","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","40104110","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","40104111","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","40104112","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","40104113","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","40104114","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","40104115","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","40104116","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","40104117","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","40104118","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","40104119","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","40104120","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Online Digital E M 5 10 Mins","40104121","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.7","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","40104122","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.71","86.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","40104123","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","40104124","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tap Block Bilat By Injctn(S)","40104125","CDM","983","RC","64488","HCPCS","","","facility","both","","","","419.5","419.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lsh W/T/O Ut 250 G Or Less","40104126","CDM","983","RC","58542","HCPCS","","","facility","both","","","","2325.07","2325.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","40104127","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Joint/Bursa W/Us","40104128","CDM","983","RC","20611","HCPCS","","","facility","both","","","","297.96","297.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sedat Endo Service >5Yrs","40104129","CDM","983","RC","G0500","HCPCS","","","facility","both","","","","187.39","187.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Aa/Strd Ax Nerve Img","40104130","CDM","983","RC","64417","HCPCS","","","facility","both","","","","496.13","496.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","40104131","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appl Modality 1 Lllt Po Pain","40104132","CDM","983","RC","97037","HCPCS","","","facility","both","","","","134.16","134.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revj/Rmvl Nea Pn W/Int Nstim","40104133","CDM","983","RC","64598","HCPCS","","","facility","both","","","","7005.16","7005.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins/Rplcm Prq Eltrd Ra Pn Ea","40104134","CDM","983","RC","64597","HCPCS","","","facility","both","","","","2300.04","2300.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins/Rplcmt Prq Eltrd Ra Pn 1","40104135","CDM","983","RC","64596","HCPCS","","","facility","both","","","","7005.16","7005.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx Tghtrp Ribertag Acl","40105738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","703.5","703.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40105739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 24D 2-0 Truespan","40105741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","977.25","977.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx Truespan 0D Peek","40105742","CDM","272","RC","","","","","facility","both","","","","1034.51","1034.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peritoneal Catheter","40105769","CDM","278","RC","","","","","facility","both","","","","2171.4","2171.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bandage Esmark","40111288","CDM","272","RC","","","","","facility","both","","","","1530.38","1530.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter, Embolectomy","40113979","CDM","278","RC","C1757","HCPCS","","","facility","both","","","","4146.27","4146.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Cholangiogrm","40131005","CDM","272","RC","","","","","facility","both","","","","2378.75","2378.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapling, Gia 50 Multifire Uni","40134306","CDM","272","RC","","","","","facility","both","","","","6787.5","6787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapling, Gia50 Disp Stapler","40134314","CDM","272","RC","","","","","facility","both","","","","10024.88","10024.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapling, Tta55-Prem 3.5","40134355","CDM","272","RC","","","","","facility","both","","","","8623.69","8623.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stapling, Ta 55 Prem 4.8","40134363","CDM","272","RC","","","","","facility","both","","","","8911.95","8911.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40181745","CDM","278","RC","","","","","facility","both","","","","11582.02","11582.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dermahook","40182081","CDM","272","RC","","","","","facility","both","","","","147.5","147.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholangiograph Set","40182537","CDM","272","RC","","","","","facility","both","","","","5068.89","5068.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 30/3.5 Stapler","40182578","CDM","272","RC","","","","","facility","both","","","","7152.5","7152.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Finger Trap, Disp","40182867","CDM","272","RC","","","","","facility","both","","","","1151.43","1151.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia Reload 4.8","40183428","CDM","272","RC","","","","","facility","both","","","","6106.93","6106.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia Reload 2.5Mm","40183444","CDM","272","RC","","","","","facility","both","","","","6912.5","6912.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Clip Applier Lrg","40183667","CDM","278","RC","","","","","facility","both","","","","12653.55","12653.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Super Anchors","40183675","CDM","278","RC","","","","","facility","both","","","","7255","7255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kronner Manipujector","40183840","CDM","272","RC","","","","","facility","both","","","","1848.82","1848.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gii Quick Anchor W/Inserter","40184038","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","12711.56","12711.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureteral Balloon Cath 9Fr","40184624","CDM","272","RC","C1726","HCPCS","","","facility","both","","","","2017.31","2017.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corkscrew - Ar1920Su","40186132","CDM","272","RC","","","","","facility","both","","","","917.5","917.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"T-Tube Bard","40190068","CDM","272","RC","","","","","facility","both","","","","1255","1255","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Stim-Locatr","40190357","CDM","272","RC","","","","","facility","both","","","","3582.48","3582.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Felt Teflon","40190407","CDM","278","RC","","","","","facility","both","","","","1642.78","1642.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glidewire","40190589","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","2231.25","2231.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Auto Sut Load Deea","40190712","CDM","272","RC","","","","","facility","both","","","","24635.63","24635.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conformer","40190886","CDM","272","RC","","","","","facility","both","","","","711.38","711.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Groshong Valve 8Fr","40191132","CDM","278","RC","C1751","HCPCS","","","facility","both","","","","33410.72","33410.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shunt Javid-Carot","40191264","CDM","272","RC","","","","","facility","both","","","","3067.5","3067.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vein Stripper","40191603","CDM","272","RC","","","","","facility","both","","","","1981.25","1981.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aut Sut Unit Dt90","40191769","CDM","272","RC","","","","","facility","both","","","","11651.06","11651.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Nasal","40191819","CDM","271","RC","","","","","facility","both","","","","325.5","325.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kirschner Wire Pl","40191900","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","946.82","946.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Steinman Pin Smth","40191959","CDM","278","RC","","","","","facility","both","","","","1023.75","1023.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Barbed Staple","40191991","CDM","272","RC","","","","","facility","both","","","","812","812","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40192064","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1215.5","1215.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrode Coag","40192890","CDM","272","RC","","","","","facility","both","","","","471.19","471.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arch Bar","40193054","CDM","272","RC","","","","","facility","both","","","","589.31","589.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sequra Basket","40193450","CDM","272","RC","","","","","facility","both","","","","11498","11498","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ta Staples 30 3V","40193526","CDM","272","RC","","","","","facility","both","","","","4207.5","4207.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rntry Malecot Cat","40193658","CDM","272","RC","","","","","facility","both","","","","3563.44","3563.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgical/Oxycel","40193773","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","2710.12","2710.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Dil Cath","40193807","CDM","272","RC","","","","","facility","both","","","","15416.63","15416.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suprapub Cath","40193815","CDM","272","RC","C2627","HCPCS","","","facility","both","","","","3220.88","3220.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Derma Carriers","40193823","CDM","272","RC","","","","","facility","both","","","","965.93","965.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dble J Stent","40194086","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","18298.23","18298.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Applier","40194342","CDM","272","RC","","","","","facility","both","","","","7696.25","7696.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Wires","40194367","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1533.71","1533.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enhance Mixer","40194532","CDM","272","RC","","","","","facility","both","","","","6058.75","6058.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tur Cable","40194664","CDM","272","RC","","","","","facility","both","","","","773.04","773.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcp Plt 2-5Hole","40194995","CDM","272","RC","","","","","facility","both","","","","3252.9","3252.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcp Plt Nr 6-9","40195000","CDM","272","RC","","","","","facility","both","","","","6207","6207","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcp Plt Br6-7","40195018","CDM","272","RC","","","","","facility","both","","","","5928.3","5928.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dcp Plt 8-14","40195034","CDM","272","RC","","","","","facility","both","","","","6012.3","6012.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Cement, Zimmer Palico","40195208","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1697.72","1697.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Auto Transfusion","40195307","CDM","390","RC","","","","","facility","both","","","","20000","20000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tls Drain","40195620","CDM","272","RC","","","","","facility","both","","","","1826.71","1826.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Autotransfusion Suction Tube","40195737","CDM","272","RC","","","","","facility","both","","","","2637.33","2637.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto With Eswl","40195851","CDM","360","RC","","","","","facility","both","","","","22273","22273","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubing-3 M Arthroscopy","40195950","CDM","272","RC","","","","","facility","both","","","","2782.5","2782.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Metra Ps Uplift Kit","40196123","CDM","272","RC","","","","","facility","both","","","","6900","6900","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Hernia, Groin Perfix Plug","40196131","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","4999.39","4999.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydrix Acell Derm Allograft4X7","40196149","CDM","636","RC","Q4101","HCPCS","","","facility","both","","","","4113.9","4113.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydrix Acell Derm Allograft6X8","40196156","CDM","636","RC","Q4101","HCPCS","","","facility","both","","","","7084.35","7084.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 12Mm Universal","40196164","CDM","272","RC","","","","","facility","both","","","","1277.09","1277.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40196198","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2001.44","2001.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Starion Thermal Welder","40196214","CDM","270","RC","","","","","facility","both","","","","2960.05","2960.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ventralex Hernia Patch","40196230","CDM","272","RC","","","","","facility","both","","","","5573.75","5573.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligasure 10Mm","40196248","CDM","272","RC","","","","","facility","both","","","","5083.75","5083.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Femoral Stem Size 10-18","40196255","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","32456.29","32456.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Femoral Stem Advocate Cem12-16","40196263","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","26832.49","26832.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Shell","40196271","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","8274.5","8274.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Liner","40196289","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","5097.63","5097.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Distal Centralizer 9-19","40196297","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1694.31","1694.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disp Catheter Passer","40196313","CDM","272","RC","","","","","facility","both","","","","1712.5","1712.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Femoral Head","40196347","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","7135.38","7135.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"5Mm Corkscrew Anchor #2 Fiberw","40196370","CDM","278","RC","","","","","facility","both","","","","3869.78","3869.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Putty, Grafton","40196420","CDM","278","RC","","","","","facility","both","","","","9705","9705","","","","","","","","","","","","","Gross Charge Type: Standard"
"External Fixation Device","40196503","CDM","278","RC","","","","","facility","both","","","","11085.48","11085.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phaco Pack","40196529","CDM","272","RC","","","","","facility","both","","","","637.5","637.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 30-2.5 Univ Roticulat","40196578","CDM","272","RC","","","","","facility","both","","","","2076.14","2076.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 30-3.5 Univ Roticulat","40196586","CDM","272","RC","","","","","facility","both","","","","2137.31","2137.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 45-2.5 Univ Roticulat","40196594","CDM","272","RC","","","","","facility","both","","","","2466.25","2466.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 45-3.5 Univ Roticulat","40196636","CDM","272","RC","","","","","facility","both","","","","2436.19","2436.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 60-2.5 Univ Roticulat","40196644","CDM","272","RC","","","","","facility","both","","","","2640","2640","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Gia 60-3.5 Univ Roticulat","40196651","CDM","272","RC","","","","","facility","both","","","","2280.11","2280.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm Lcp 8 Hole 111Mm","40196669","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3950.63","3950.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40196677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5086.25","5086.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm Lcp 10Hole 137Mm","40196685","CDM","278","RC","","","","","facility","both","","","","4011.25","4011.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm Lcp 12Hole 163Mm","40196701","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","5781.75","5781.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm 3/8H Hd/Shft97Mm","40196859","CDM","278","RC","","","","","facility","both","","","","6628.75","6628.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40196982","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2700.6","2700.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm Lcp 6 Hole 85Mm","40196990","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3610.69","3610.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197055","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2380.63","2380.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197063","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2380.63","2380.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes Lcp 1/3 Tub 7Hole 81Mm","40197071","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2429.38","2429.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197089","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2565.88","2565.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes Lcp 1/3 Tub 9Hole105Mm","40197097","CDM","278","RC","","","","","facility","both","","","","1973.75","1973.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes Lcp 1/3 Tub10Hole117Mm","40197105","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2565.88","2565.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes Lcp 1/3 Tub12Hole141Mm","40197113","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1712.55","1712.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 3.5Mm 3/3H Hd/Shft52Mm","40197121","CDM","278","RC","","","","","facility","both","","","","3878.75","3878.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pain Pump (Zimmer)","40197337","CDM","272","RC","","","","","facility","both","","","","2224.68","2224.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Floseal Hemostatic Matrix","40197352","CDM","270","RC","","","","","facility","both","","","","2570.43","2570.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligasure Atlas 20 Cm","40197394","CDM","272","RC","","","","","facility","both","","","","4129.13","4129.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pelvicol 2X7 Cm","40197402","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","8168.1","8168.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decathalon Gold Hemodialysis C","40197410","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","5550.8","5550.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bard Power Port","40197436","CDM","278","RC","C1788","HCPCS","","","facility","both","","","","6013.79","6013.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mini Arc Single Incision Sling","40197444","CDM","278","RC","C1771","HCPCS","","","facility","both","","","","18384.85","18384.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Morcellator","40197528","CDM","272","RC","C1782","HCPCS","","","facility","both","","","","4043.81","4043.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vascular Bifurcated","40197536","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","5239.5","5239.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Vascular Heparin","40197552","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","29763.55","29763.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197560","CDM","278","RC","C1768","HCPCS","","","facility","both","","","","5900.38","5900.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolapse Repair System Ant/Pos","40197578","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","19000.8","19000.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Cancellous Bone Chips","40197586","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","5062.43","5062.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","837.77","837.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kugel Hernia Patch","40197602","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","8572.5","8572.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197610","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.44","363.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw End Caps","40197628","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2041","2041","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Wire","40197636","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","730.02","730.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40197644","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2944.5","2944.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Washer","40197660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","301.7","301.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Doyle Ii Airway","40198814","CDM","272","RC","","","","","facility","both","","","","1696.7","1696.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Irrigator","40199119","CDM","270","RC","","","","","facility","both","","","","10833.38","10833.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pk Bipolar Cutter 10Mm","40199234","CDM","272","RC","","","","","facility","both","","","","5416.25","5416.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pk Bipolar Cutter 5Mm","40199242","CDM","272","RC","","","","","facility","both","","","","5206.25","5206.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibrin Glue 2Ml","40199267","CDM","272","RC","","","","","facility","both","","","","2509.55","2509.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fibrin Glue 5Ml","40199275","CDM","272","RC","","","","","facility","both","","","","6218.1","6218.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","40199283","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1382.06","1382.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 30 Min Cl1","40710006","CDM","710","RC","","","","","facility","both","","","","11260","11260","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl2","40720005","CDM","710","RC","","","","","facility","both","","","","25885","25885","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl3","40730004","CDM","710","RC","","","","","facility","both","","","","37774","37774","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery 60Min Cl4","40740003","CDM","710","RC","","","","","facility","both","","","","53960","53960","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recovery Ea Addl Min","40750002","CDM","710","RC","","","","","facility","both","","","","372","372","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level I","40800005","CDM","510","RC","99211","HCPCS","","","facility","both","","","","232","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Blood Count Hemoglobin (Hgb)","40800039","CDM","300","RC","85018","HCPCS","","","facility","both","","","QW","4.84","4.84","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Mod Qw Protime W/ Inr","40800047","CDM","300","RC","85610","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Visit Coumadin New Level 1","40800056","CDM","510","RC","99211","HCPCS","","","facility","both","","","","232","232","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Surg C-Sect","41010125","CDM","360","RC","","","","","facility","both","","","","52519","52519","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob-Surg C Section (Repeat)","41010158","CDM","360","RC","","","","","facility","both","","","","52519","52519","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Sect W/Tub Lig (Repeat)","41010224","CDM","360","RC","","","","","facility","both","","","","55958","55958","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tubal Ligation","41010307","CDM","360","RC","","","","","facility","both","","","","14549","14549","","","","","","","","","","","","","Gross Charge Type: Standard"
"Salpingectomy Comp/Part Unil O","41026882","CDM","360","RC","","","","","facility","both","","","","14549","14549","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Sect W/Bilat Salpingectomy (","41026883","CDM","360","RC","","","","","facility","both","","","","55958","55958","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Sect W/Bilat Salpingectomy","41026884","CDM","360","RC","","","","","facility","both","","","","55958","55958","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41091836","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4540.25","4540.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Steinman Pin Thrd","41091885","CDM","272","RC","","","","","facility","both","","","","835","835","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Osteotomy","41092099","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","10401.3","10401.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Compression","41092156","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1241.5","1241.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Margin Map","41092198","CDM","272","RC","","","","","facility","both","","","","656.67","656.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monarc Subfascial Hammock","41092206","CDM","272","RC","","","","","facility","both","","","","13651.31","13651.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh (Bard Pelvisoft Collagen)","41092214","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","10126.6","10126.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infuse Bone Graft","41092222","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","49912.5","49912.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hydrotherm Ablator Proced Set","41092586","CDM","272","RC","","","","","facility","both","","","","8063.56","8063.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protac 5Mm","41092818","CDM","272","RC","","","","","facility","both","","","","2378.75","2378.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Clip Small 5Mm","41092826","CDM","272","RC","","","","","facility","both","","","","3561.44","3561.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sclerosol Talc","41092966","CDM","272","RC","","","","","facility","both","","","","2592.45","2592.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Fiber(Green Light Laser)","41092974","CDM","272","RC","","","","","facility","both","","","","12348","12348","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capio Suture Capturing Device","41092982","CDM","272","RC","","","","","facility","both","","","","3777.38","3777.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capio Suture (Polygcolic)","41092990","CDM","272","RC","","","","","facility","both","","","","385.84","385.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Capio Suture (Monodek)","41093006","CDM","272","RC","","","","","facility","both","","","","385.84","385.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Novasure Endometrial Ablation","41093055","CDM","270","RC","","","","","facility","both","","","","12028.06","12028.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synthes 6.5 Cannul Fullth","41093592","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2884.35","2884.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh, Marlex 3X6","41093873","CDM","272","RC","","","","","facility","both","","","","2593.75","2593.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stryker Hood Cover","41093899","CDM","272","RC","","","","","facility","both","","","","616.03","616.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Argon Beam Handpiece (Open)","41093956","CDM","272","RC","","","","","facility","both","","","","631.25","631.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stimulating Block Needle","41094079","CDM","272","RC","","","","","facility","both","","","","947.5","947.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh Lge Preshaped W/ Keyhole","41094087","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","3495.45","3495.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094103","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","17286.02","17286.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligasure Impact Lf 4200","41094137","CDM","272","RC","","","","","facility","both","","","","6142.92","6142.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Anchor Bio-Swivelock","41094186","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3923.06","3923.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expressew","41094202","CDM","272","RC","","","","","facility","both","","","","992.25","992.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Trochanteric Fixation","41094278","CDM","278","RC","","","","","facility","both","","","","4753.13","4753.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094302","CDM","272","RC","","","","","facility","both","","","","2353.75","2353.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infuse Bone Graft Medium","41094328","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","41471.85","41471.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cememt Mixing Sx Revolution","41094386","CDM","272","RC","","","","","facility","both","","","","1629.65","1629.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Harmonic Scalpel Hand Control5","41094394","CDM","270","RC","","","","","facility","both","","","","4676.25","4676.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra Compartmental Quick Pres","41094402","CDM","270","RC","","","","","facility","both","","","","803.25","803.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094460","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","2136.88","2136.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dhs Plate 46Mm","41094478","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","6534.13","6534.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bipolar Sealer Aquamants","41094486","CDM","272","RC","","","","","facility","both","","","","4166.25","4166.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sys Sahara Chest Drain Lf","41094494","CDM","272","RC","","","","","facility","both","","","","540.98","540.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094502","CDM","274","RC","L0140","HCPCS","","","facility","both","","","","177.45","177.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Pin Bioabs 1.5/2.0X100","41094510","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2244.51","2244.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X85Mm","41094593","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","893.05","893.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X90Mm","41094594","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1095.25","1095.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X48Mm","41094595","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","714.44","714.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X42Mm","41094596","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","893.05","893.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X38Mm","41094597","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","893.05","893.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann Va Lck 5.0X80Mm","41094598","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1160.97","1160.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094599","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","726.86","726.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 3.5 Pubic Symphysis 6H","41094600","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2102.5","2102.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Pelvic Cortex 204.67","41094602","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","170.53","170.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Pelvic Cortex 204.67","41094603","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","131.18","131.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.058","41094606","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.056","41094607","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","644.96","644.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.060","41094608","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Lunderquist Exh 260","41094621","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","262","262","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Super Intro R/O","41094623","CDM","272","RC","C1894","HCPCS","","","facility","both","","","","39.42","39.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 X 10Mm Va 02.211.010","41094626","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","644.96","644.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 X 34Mm Va 02.211.034","41094627","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","500.85","500.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.216","41094628","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","172.25","172.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.218","41094629","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","132.5","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.220","41094630","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","132.5","132.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 230Mm Fluted 315.92","41094633","CDM","272","RC","","","","","facility","both","","","","705.44","705.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill 3.2Mm Perc 324.212","41094634","CDM","272","RC","","","","","facility","both","","","","658.88","658.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7Mm Va Lck 02.211.052","41094635","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","472.5","472.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.242","41094637","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","106","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.244","41094638","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","106","106","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.536","41094641","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","214.65","214.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.542","41094642","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","276.41","276.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.146","41094644","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","426","426","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.138","41094646","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","564.45","564.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.224","41094647","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","151.58","151.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.544","41094649","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","168.75","168.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.552","41094650","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","135","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.554","41094651","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","178.88","178.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.550","41094653","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.38","219.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.038","41094659","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","393.75","393.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.046","41094660","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","393.75","393.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.054","41094661","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","330.75","330.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.232","41094662","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","88","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.236","41094663","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","88","88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.250","41094665","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","92.4","92.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.142","41094667","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","443.75","443.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.128","41094668","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","452.63","452.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 5.0 Peri Va Lck 02.231.0","41094670","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","723.75","723.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 5.0 Peri Va Lck 02.231.0","41094671","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","579","579","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Va Lck 02.211.040","41094672","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","393.75","393.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.132","41094673","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","470.38","470.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Va Lck 02.127.134","41094674","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","470.38","470.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp 6H 02.118","41094675","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2772","2772","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp 02.118.20","41094676","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2951.55","2951.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp Rt 02.118","41094677","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2742.6","2742.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp Lt 02.118","41094678","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2317.25","2317.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp Rt 02.118","41094679","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4515.88","4515.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7 Va Lcp 4H Lt 02.118.","41094680","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1863.75","1863.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.560","41094682","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","168.75","168.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate  2.7/3.5 Va Lcp 02.118.2","41094684","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3764.25","3764.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 3.5 Cortex 02.206.214","41094685","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","143","143","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.540","41094686","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.38","219.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.530","41094687","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","168.75","168.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.534","41094688","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","219.38","219.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 4.5 Ti Multilck 04.019.0","41094689","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","566","566","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7 Va Lcp 02.118.405","41094691","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2543.12","2543.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 2.7/3.5 Va Lcp Rt 02.118","41094692","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3728.81","3728.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.526","41094694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","232.54","232.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw 2.7 Meta 02.118.528","41094695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","135","135","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 6X26","41094699","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","292.38","292.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 6X20","41094700","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 6X30","41094701","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","286.65","286.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 6X24","41094702","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","303.85","303.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 7X28","41094707","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","286.65","286.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 7X30","41094708","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Percuflex Ureteral Stent 8X28","41094713","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Void Filler 07.704.010S","41094716","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","4264.19","4264.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nail Intramedllary Tfn","41094717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1512.6","1512.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Bit 500Mm 03.037.022","41094718","CDM","272","RC","","","","","facility","both","","","","1092.2","1092.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Midas Rex T12Mh25D","41094719","CDM","272","RC","","","","","facility","both","","","","297.4","297.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh-Physiomesh Monocryl","41094721","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","1419.7","1419.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prevena Plus Incision System","41094722","CDM","270","RC","","","","","facility","both","","","","1023.75","1023.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter 16F Malecot Nephro","41094723","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","193.72","193.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter 20F Malecot Nephro","41094724","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","193.72","193.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter 24F Malecot Nephro","41094725","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","193.72","193.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter 14F Malecot Nephro","41094726","CDM","272","RC","C1729","HCPCS","","","facility","both","","","","193.72","193.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Facial Incising Needle","41094727","CDM","272","RC","","","","","facility","both","","","","88.55","88.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Tenodesis 4.75X15Mm","41094728","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","724.5","724.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Endoscopic 0.35","41094732","CDM","272","RC","C1769","HCPCS","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 30Mm Qfix","41094735","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 34Mm Qfix","41094736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094737","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 40Mm Qfix","41094738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 42Mm Qfix","41094739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 44Mm Qfix","41094740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 46Mm Qfix","41094741","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","363.3","363.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Bcmps 28Mm 10Mm","41094742","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","523.11","523.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 23Mm 10Mm","41094744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 23Mm 7Mm","41094745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 23Mm 9Mm","41094746","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 30Mm 10Mm","41094747","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 30Mm 11Mm","41094748","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Tcp Plga 30Mm 8Mm","41094749","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","800.1","800.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrex Arthroscopic Fixation","41094750","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1386","1386","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","41094751","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Covid Mod 12Y+ 0.5Ml","41800001","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Admin Sarscov2 Vacc 1 Dose","41800002","CDM","983","RC","90480","HCPCS","","","facility","both","","","","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bilirubin Total Transcut","41800003","CDM","983","RC","88720","HCPCS","","","facility","both","","","","10.38","10.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Fluzone 0.5Ml Trivalent","41800005","CDM","999","RC","90656","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Flumist Nasal Trivalent","41800007","CDM","999","RC","90660","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Covid Mod 6M-11Y 0.25Ml","41800009","CDM","999","RC","91321","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Pf Audiometry Puretone Screen","41800010","CDM","983","RC","92551","HCPCS","","","facility","both","","","","35.79","35.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Covid Mod 12Y+ 0.5Ml(2023","41800011","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Office Visit New Pt Lvl Ii","41800012","CDM","983","RC","99202","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Covid Mod 6M-11Y 0.25Ml(2","41800013","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Office Visit New Pt Lvl Iii","41800020","CDM","983","RC","99203","HCPCS","","","facility","both","","","","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rem Contraceptive Cap","41800022","CDM","983","RC","11976","HCPCS","","","facility","both","","","","350.49","350.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rem Foreign Body Foot","41800024","CDM","983","RC","28190","HCPCS","","","facility","both","","","","648.65","648.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Care Mgmt 14 Day Disc","41800026","CDM","983","RC","99495","HCPCS","","","facility","both","","","","450.07","450.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Trans Care Mgmt 7 Day Disch","41800028","CDM","983","RC","99496","HCPCS","","","facility","both","","","","593.84","593.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41800031","CDM","983","RC","90472","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41800038","CDM","983","RC","99204","HCPCS","","","facility","both","","","","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41800046","CDM","983","RC","99205","HCPCS","","","facility","both","","","","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41800053","CDM","983","RC","99211","HCPCS","","","facility","both","","","","58.5","58.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41800055","CDM","983","RC","96372","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41800061","CDM","983","RC","99212","HCPCS","","","facility","both","","","","111.38","111.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Init","41800063","CDM","983","RC","96365","HCPCS","","","facility","both","","","","184.51","184.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Add-On","41800065","CDM","983","RC","96366","HCPCS","","","facility","both","","","","54.69","54.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Remote Dx Retinal Imaging","41800067","CDM","983","RC","92227","HCPCS","","","facility","both","","","","35.68","35.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Event Recorder","41800068","CDM","983","RC","93268","HCPCS","","","facility","both","","","","527.48","527.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41800079","CDM","983","RC","99213","HCPCS","","","facility","both","","","","180.81","180.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehisc Smpl","41800081","CDM","983","RC","12020","HCPCS","","","facility","both","","","","733.69","733.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41800087","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41800095","CDM","983","RC","99215","HCPCS","","","facility","both","","","","348.94","348.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hydration Iv Inf Init","41800108","CDM","983","RC","96360","HCPCS","","","facility","both","","","","87.67","87.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41800111","CDM","983","RC","99242","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Hep B-Comvax","41800128","CDM","999","RC","90748","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Office Consult Lvl Iii","41800129","CDM","983","RC","99243","HCPCS","","","facility","both","","","","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41800137","CDM","983","RC","99244","HCPCS","","","facility","both","","","","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41800145","CDM","983","RC","99245","HCPCS","","","facility","both","","","","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 5-10 Min","41800147","CDM","983","RC","99441","HCPCS","","","facility","both","","","","33.12","33.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drivers Physical","41800152","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snellen Eye Test","41800156","CDM","983","RC","99173","HCPCS","","","facility","both","","","","18.91","18.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sports/School Physical","41800160","CDM","983","RC","99499","HCPCS","","","facility","both","","","","36.05","36.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Employment Physical","41800178","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Developmental Screen W/Score","41800179","CDM","983","RC","96110","HCPCS","","","facility","both","","","","26.14","26.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Global","41800180","CDM","983","RC","93000","HCPCS","","","facility","both","","","","41.86","41.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route 1St","41800182","CDM","983","RC","90460","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route Ea Ad","41800184","CDM","983","RC","90461","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis Small Joint","41800186","CDM","983","RC","20600","HCPCS","","","facility","both","","","","121.33","121.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Joint/Bursa W/O Us","41800194","CDM","983","RC","20605","HCPCS","","","facility","both","","","","125.78","125.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Major Joint W/O Us","41800202","CDM","983","RC","20610","HCPCS","","","facility","both","","","","148.94","148.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion 1St","41800210","CDM","983","RC","17000","HCPCS","","","facility","both","","","","163.07","163.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct Skin Lesion Ea 2-14","41800228","CDM","983","RC","17003","HCPCS","","","facility","both","","","","15.57","15.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Eye Exam W/Photo","41800230","CDM","983","RC","92250","HCPCS","","","facility","both","","","","113.51","113.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged Svcs W/O Contact","41800231","CDM","983","RC","99358","HCPCS","","","facility","both","","","","258.65","258.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion >15","41800236","CDM","983","RC","17004","HCPCS","","","facility","both","","","","398.14","398.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct B9 Lesion 1-14","41800244","CDM","983","RC","17110","HCPCS","","","facility","both","","","","286.4","286.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Flat Warts >15","41800251","CDM","983","RC","17111","HCPCS","","","facility","both","","","","333.91","333.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41800253","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41800254","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41800255","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41800256","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41800257","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chron Care Mgmt Srvc 20 Min","41800258","CDM","983","RC","99490","HCPCS","","","facility","both","","","","98.76","98.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Skin Tags 15 Lesions","41800285","CDM","983","RC","11200","HCPCS","","","facility","both","","","","221.82","221.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Tags Ea Add'l 10","41800293","CDM","983","RC","11201","HCPCS","","","facility","both","","","","44.08","44.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","41800301","CDM","983","RC","10160","HCPCS","","","facility","both","","","","324.82","324.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endometrial Biopsy","41800327","CDM","983","RC","58100","HCPCS","","","facility","both","","","","236.26","236.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/O Imaging","41800329","CDM","983","RC","32554","HCPCS","","","facility","both","","","","563.22","563.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","41800330","CDM","983","RC","32555","HCPCS","","","facility","both","","","","796.4","796.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Absc Smpl Or Sgl","41800335","CDM","983","RC","10060","HCPCS","","","facility","both","","","","300.72","300.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","41800343","CDM","983","RC","10140","HCPCS","","","facility","both","","","","424.11","424.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Sheath","41800350","CDM","983","RC","20550","HCPCS","","","facility","both","","","","131.33","131.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Basic Metabolic Panel","41800355","CDM","301","RC","80047","HCPCS","","","facility","both","","","QW","25","25","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Inonized Calcuim (Ca)","41800356","CDM","301","RC","82330","HCPCS","","","facility","both","","","QW","25","25","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Tco2","41800357","CDM","301","RC","82374","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Chloride (Cl)","41800358","CDM","301","RC","82435","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Creatinine (Crea)","41800359","CDM","301","RC","82565","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Potassium (K)","41800361","CDM","301","RC","84132","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Sodium (Na)","41800362","CDM","301","RC","84295","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Urea","41800363","CDM","301","RC","84520","HCPCS","","","facility","both","","","QW","7","7","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hematocrit (Hct)","41800364","CDM","305","RC","85014","HCPCS","","","facility","both","","","QW","5","5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hemoglobin (Hb)","41800365","CDM","305","RC","85018","HCPCS","","","facility","both","","","QW","5","5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Flu","41800366","CDM","300","RC","87804","HCPCS","","","facility","both","","","QW","28","28","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Rsv","41800367","CDM","306","RC","87807","HCPCS","","","facility","both","","","QW","24","24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Blood Lead","41800369","CDM","300","RC","83655","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Spinal Puncture Lumbar Dx","41800376","CDM","983","RC","62270","HCPCS","","","facility","both","","","","349.54","349.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Impact Ear Wax W/Instr Uni","41800418","CDM","983","RC","69210","HCPCS","","","facility","both","","","","114.52","114.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Simple","41800426","CDM","983","RC","10120","HCPCS","","","facility","both","","","","383.78","383.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Typpanometry","41800459","CDM","983","RC","92567","HCPCS","","","facility","both","","","","39.1","39.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Preventive New Pt < 1Yr Old","41800467","CDM","983","RC","99381","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Preventive New Pt 1-4 Yrs","41800475","CDM","983","RC","99382","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Preventive New Pt 5-11 Yrs","41800483","CDM","983","RC","99383","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 12-17 Yrs","41800491","CDM","983","RC","99384","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Preventive New Pt 18-39 Yrs","41800509","CDM","983","RC","99385","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 40-64 Yrs","41800517","CDM","983","RC","99386","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt Over 65 Yrs","41800525","CDM","983","RC","99387","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt Under 1 Yr","41800533","CDM","983","RC","99391","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 1-4 Yrs","41800541","CDM","983","RC","99392","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 5-11 Yrs","41800558","CDM","983","RC","99393","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 12-17 Yrs","41800566","CDM","983","RC","99394","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 18-39 Yrs","41800574","CDM","983","RC","99395","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 40-64 Yrs","41800582","CDM","983","RC","99396","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 65>","41800590","CDM","983","RC","99397","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simpl Avulsion Nail Plt Single","41800608","CDM","983","RC","11730","HCPCS","","","facility","both","","","","277.23","277.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avulsion Nail Ea 2+","41800616","CDM","983","RC","11732","HCPCS","","","facility","both","","","","82.69","82.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails 1-5","41800624","CDM","983","RC","11720","HCPCS","","","facility","both","","","","81.76","81.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails >6","41800632","CDM","983","RC","11721","HCPCS","","","facility","both","","","","111.34","111.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Nail/Matrix Perm Remove","41800640","CDM","983","RC","11750","HCPCS","","","facility","both","","","","391.83","391.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Arm","41800657","CDM","983","RC","29065","HCPCS","","","facility","both","","","","234.04","234.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Arm","41800665","CDM","983","RC","29075","HCPCS","","","facility","both","","","","211.69","211.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Gauntlet","41800673","CDM","983","RC","29085","HCPCS","","","facility","both","","","","232.72","232.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Leg","41800681","CDM","983","RC","29345","HCPCS","","","facility","both","","","","328.65","328.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Leg","41800699","CDM","983","RC","29405","HCPCS","","","facility","both","","","","195.56","195.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Arm","41800707","CDM","983","RC","29105","HCPCS","","","facility","both","","","","199.74","199.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Arm","41800715","CDM","983","RC","29125","HCPCS","","","facility","both","","","","160.23","160.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Finger","41800723","CDM","983","RC","29130","HCPCS","","","facility","both","","","","99.15","99.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Leg","41800731","CDM","983","RC","29505","HCPCS","","","facility","both","","","","212.26","212.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Leg","41800749","CDM","983","RC","29515","HCPCS","","","facility","both","","","","173.43","173.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Gauntlet,Boot,Body Cast","41800756","CDM","983","RC","29700","HCPCS","","","facility","both","","","","155.26","155.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41800765","CDM","983","RC","90471","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41800773","CDM","983","RC","90472","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Fingerstick","41800939","CDM","300","RC","82962","HCPCS","","","facility","both","","","","6","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41800940","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","18","18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Finger Stick","41800941","CDM","300","RC","36416","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Blood","41800954","CDM","300","RC","82270","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pregnancy Test","41800962","CDM","300","RC","81025","HCPCS","","","facility","both","","","","20","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spun Hematocrit","41800970","CDM","300","RC","85013","HCPCS","","","facility","both","","","","16","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strep Screen","41800988","CDM","300","RC","87880","HCPCS","","","facility","both","","","QW","31","31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Ua W/ Micro","41800996","CDM","300","RC","81000","HCPCS","","","facility","both","","","","9","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/O Micro","41801002","CDM","300","RC","81002","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wet Mount","41801010","CDM","300","RC","87210","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Ppd","41801028","CDM","300","RC","86580","HCPCS","","","facility","both","","","","22","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer","41801531","CDM","983","RC","94640","HCPCS","","","facility","both","","","","47.13","47.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 12.6-20Cm","41801994","CDM","983","RC","12005","HCPCS","","","facility","both","","","","411.16","411.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Face 0.6-1.0 Cm","41802810","CDM","983","RC","11311","HCPCS","","","facility","both","","","","347.77","347.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 3-4 Body Regions","41802844","CDM","983","RC","98926","HCPCS","","","facility","both","","","","108.56","108.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 1-2 Body Regions","41802869","CDM","983","RC","98925","HCPCS","","","facility","both","","","","75.66","75.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 5-6 Body Regions","41802885","CDM","983","RC","98927","HCPCS","","","facility","both","","","","141.71","141.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 7-8 Body Regions","41802901","CDM","983","RC","98928","HCPCS","","","facility","both","","","","172.34","172.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 9-10 Body Regions","41802927","CDM","983","RC","98929","HCPCS","","","facility","both","","","","204.66","204.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Ext Eczema/Infect Skin","41803024","CDM","983","RC","11000","HCPCS","","","facility","both","","","","140.33","140.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Lesion Face <0.5Cm","41803057","CDM","983","RC","11440","HCPCS","","","facility","both","","","","355.27","355.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy/Excise Of Lesion Cervix","41803115","CDM","983","RC","57500","HCPCS","","","facility","both","","","","361.47","361.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Lesion","41803149","CDM","983","RC","46922","HCPCS","","","facility","both","","","","748.93","748.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk >4 Cm","41803172","CDM","983","RC","11406","HCPCS","","","facility","both","","","","770.4","770.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Wnd 2.6-7.5 Cm","41803206","CDM","983","RC","12002","HCPCS","","","facility","both","","","","270","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 0.5Cm Or <","41803222","CDM","983","RC","11310","HCPCS","","","facility","both","","","","295.63","295.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Benign Lesion >4.0Cm","41803248","CDM","983","RC","11426","HCPCS","","","facility","both","","","","812.18","812.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Othr Ben Les 0.6-1.0Cm","41803263","CDM","983","RC","11441","HCPCS","","","facility","both","","","","429.57","429.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 0.6-1Cm","41803313","CDM","983","RC","11301","HCPCS","","","facility","both","","","","309.27","309.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 1.1-2Cm","41803339","CDM","983","RC","11302","HCPCS","","","facility","both","","","","357.18","357.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Leg Ankle Deep Absc Hema","41803354","CDM","983","RC","27603","HCPCS","","","facility","both","","","","1320.48","1320.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Lesion Face 0.6-1Cm","41803362","CDM","983","RC","11641","HCPCS","","","facility","both","","","","595.73","595.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck .6-1Cm","41803370","CDM","983","RC","11306","HCPCS","","","facility","both","","","","313.06","313.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Trunk 2.1-3C","41803388","CDM","983","RC","11403","HCPCS","","","facility","both","","","","486","486","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Vulva/Perineum","41803390","CDM","983","RC","56605","HCPCS","","","facility","both","","","","230.76","230.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Penil Circumic Lesion","41803391","CDM","983","RC","54162","HCPCS","","","facility","both","","","","604.84","604.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41803392","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reagent Strip/Blood Glucose","41803393","CDM","983","RC","82948","HCPCS","","","facility","both","","","","16.5","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc B9 Les S N Ex G 1.1-2.0Cm","41803404","CDM","983","RC","11422","HCPCS","","","facility","both","","","","446.71","446.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 2.1-3C","41803420","CDM","983","RC","11423","HCPCS","","","facility","both","","","","504.35","504.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 1.1-2Cm","41803446","CDM","983","RC","11442","HCPCS","","","facility","both","","","","475.18","475.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 2.1-3Cm","41803461","CDM","983","RC","11443","HCPCS","","","facility","both","","","","558.51","558.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.5Cm<","41803487","CDM","983","RC","11600","HCPCS","","","facility","both","","","","496.42","496.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.6-1C","41803503","CDM","983","RC","11601","HCPCS","","","facility","both","","","","573.73","573.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 1.1-2C","41803529","CDM","983","RC","11602","HCPCS","","","facility","both","","","","618.19","618.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 2.1-3C","41803545","CDM","983","RC","11603","HCPCS","","","facility","both","","","","698.61","698.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.5Cm<","41803560","CDM","983","RC","11620","HCPCS","","","facility","both","","","","498.54","498.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.6-1C","41803586","CDM","983","RC","11621","HCPCS","","","facility","both","","","","575.83","575.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 1.1-2C","41803602","CDM","983","RC","11622","HCPCS","","","facility","both","","","","636.66","636.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 2.1-3C","41803628","CDM","983","RC","11623","HCPCS","","","facility","both","","","","739.35","739.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 0.5Cm <","41803644","CDM","983","RC","11640","HCPCS","","","facility","both","","","","511.04","511.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc S/N/H/F/G Mal+Mrg 3.1-4","41803645","CDM","983","RC","11624","HCPCS","","","facility","both","","","","832.98","832.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 1.1-2Cm","41803669","CDM","983","RC","11642","HCPCS","","","facility","both","","","","672.28","672.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 2.1-3Cm","41803685","CDM","983","RC","11643","HCPCS","","","facility","both","","","","782.88","782.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 7.6-12.5Cm","41803701","CDM","983","RC","12004","HCPCS","","","facility","both","","","","312.73","312.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.5Cm Or <","41803727","CDM","983","RC","12011","HCPCS","","","facility","both","","","","270.79","270.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.6-5Cm","41803743","CDM","983","RC","12013","HCPCS","","","facility","both","","","","279.91","279.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 5.1-7.5Cm","41803768","CDM","983","RC","12014","HCPCS","","","facility","both","","","","338.42","338.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41803784","CDM","983","RC","12031","HCPCS","","","facility","both","","","","636.33","636.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Scalp 2.6-7.5Cm","41803800","CDM","983","RC","12032","HCPCS","","","facility","both","","","","762.78","762.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr S/Tr/Ext 7.6-12.5","41803826","CDM","983","RC","12034","HCPCS","","","facility","both","","","","809.19","809.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter N/H/F/G 2.5Cm Or<","41803842","CDM","983","RC","12041","HCPCS","","","facility","both","","","","636","636","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 2.6-7.5Cm","41803867","CDM","983","RC","12042","HCPCS","","","facility","both","","","","751.22","751.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vacc","41803868","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","193","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ftf Counsel-Alcohol Misuse 15","41803870","CDM","983","RC","G0443","HCPCS","","","facility","both","","","","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"(Frenotomy)Incsn Lingl Frenum","41803871","CDM","983","RC","41010","HCPCS","","","facility","both","","","","542.83","542.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Vulva Perineal Abscess","41803872","CDM","983","RC","56405","HCPCS","","","facility","both","","","","312.5","312.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"(Frenotomy)Incsn Labial Frenum","41803873","CDM","983","RC","40806","HCPCS","","","facility","both","","","","263.06","263.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41803878","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41803879","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41803880","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41803881","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 7.6-12.5Cm","41803883","CDM","983","RC","12044","HCPCS","","","facility","both","","","","932.46","932.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41803884","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41803885","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41803886","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41803887","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41803888","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41803889","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41803890","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41803892","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screening For Depression","41803893","CDM","983","RC","3725F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41803894","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smk","41803895","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41803896","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41803897","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41803898","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41803899","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Falls Assess-Docd Ge2+/Yr","41803900","CDM","983","RC","1100F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Falls Assess-Docd Le1/Yr","41803901","CDM","983","RC","1101F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41803902","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Origin","41803903","CDM","983","RC","20551","HCPCS","","","facility","both","","","","135.14","135.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Focused Hlth Risk Assmt","41803904","CDM","983","RC","96160","HCPCS","","","facility","both","","","","6.67","6.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caregiver Health Risk Assmt","41803905","CDM","983","RC","96161","HCPCS","","","facility","both","","","","6.67","6.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Complex","41803906","CDM","983","RC","95972","HCPCS","","","facility","both","","","","136.23","136.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Flu Virus Vaccine","41803907","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","84","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol Misuse Scrn 15 Min Yr","41803908","CDM","983","RC","G0442","HCPCS","","","facility","both","","","","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.5Cm Or <","41803909","CDM","983","RC","12051","HCPCS","","","facility","both","","","","683.2","683.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Scrotum And Contents","41803910","CDM","983","RC","76870","HCPCS","","","facility","both","","","","269.72","269.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit To Determ Ldct Elig","41803911","CDM","983","RC","G0296","HCPCS","","","facility","both","","","","67.77","67.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dschrg Med/Current Med Merge","41803912","CDM","983","RC","1111F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advance Care Planning Tlk Doc","41803913","CDM","983","RC","1158F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C <100 Mg/Dl","41803914","CDM","983","RC","3048F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C 100 - 129 Mg/Dl","41803915","CDM","983","RC","3049F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C >=130 Mg/Dl","41803916","CDM","983","RC","3050F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Microalbuminuria Rev","41803918","CDM","983","RC","3060F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Microalbuminuria Rev - 306","41803919","CDM","983","RC","3061F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Macroalbuminuria Rev","41803920","CDM","983","RC","3062F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephropathy Doc Tx","41803921","CDM","983","RC","3066F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Low Risk For Retinopathy","41803922","CDM","983","RC","3072F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Use Txmnt Counseling","41803923","CDM","983","RC","4000F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Use Txmnt Pharmacol","41803924","CDM","983","RC","4001F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.6-5Cm","41803925","CDM","983","RC","12052","HCPCS","","","facility","both","","","","761.75","761.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Tobacco Screen Rcvd Tlk","41803926","CDM","983","RC","4004F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ace/Arb Therapy Rxd/Taken","41803927","CDM","983","RC","4010F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41803929","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41803930","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41803931","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41803932","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41803934","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","58.5","58.5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41803935","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","111.38","111.38","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41803936","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","180.81","180.81","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41803937","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41803938","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","348.94","348.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41803939","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","232.29","232.29","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41803940","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","315.63","315.63","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Repair Inter Face 5.1-7.5Cm","41803941","CDM","983","RC","12053","HCPCS","","","facility","both","","","","893.73","893.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Init Hosp Care Iii","41803942","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","465.37","465.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41803944","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41803945","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41803946","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41803947","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Bx Nail Unit","41803949","CDM","983","RC","11755","HCPCS","","","facility","both","","","","305.46","305.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","41803950","CDM","983","RC","99497","HCPCS","","","facility","both","","","","200.19","200.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ear Lavage Unilateral","41803951","CDM","983","RC","69209","HCPCS","","","facility","both","","","","37.6","37.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Pedvax Hib","41803953","CDM","999","RC","90647","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Psytx Crisis Initial 60 Min","41803956","CDM","983","RC","90839","HCPCS","","","facility","both","","","","332.71","332.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroeltrd Stim Post Tibial","41803957","CDM","983","RC","64566","HCPCS","","","facility","both","","","","327.54","327.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Flulaval 0.5Ml Inj","41803960","CDM","999","RC","90686","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"I D Pilonidal Cyst Simple","41803962","CDM","983","RC","10080","HCPCS","","","facility","both","","","","540.59","540.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pv Residual Urine","41803963","CDM","983","RC","51798","HCPCS","","","facility","both","","","","27.09","27.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy Diagnostic","41803966","CDM","983","RC","46600","HCPCS","","","facility","both","","","","266.32","266.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Skene's Glnd/Abscss/Cyst","41803967","CDM","983","RC","53060","HCPCS","","","facility","both","","","","444.32","444.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bladder Irrigation Simple","41803968","CDM","983","RC","51700","HCPCS","","","facility","both","","","","189.15","189.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Of Adhesions/Multi-1 Day","41803969","CDM","983","RC","62264","HCPCS","","","facility","both","","","","1097.75","1097.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation Of Cervical Canal","41803970","CDM","983","RC","57800","HCPCS","","","facility","both","","","","172.17","172.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Carpal Tunnel Tx Injection","41803972","CDM","983","RC","20526","HCPCS","","","facility","both","","","","189.95","189.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Drug Implant","41803973","CDM","983","RC","11982","HCPCS","","","facility","both","","","","284.05","284.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vaginal Foreign Body","41803975","CDM","983","RC","57415","HCPCS","","","facility","both","","","","404.19","404.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Bl W/Cath Insertion","41803976","CDM","983","RC","51102","HCPCS","","","facility","both","","","","585.29","585.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Excess Skn Tiss:Fa/Hand","41803979","CDM","983","RC","15837","HCPCS","","","facility","both","","","","2121.39","2121.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv 15-30Min","41803980","CDM","983","RC","G0396","HCPCS","","","facility","both","","","","83.78","83.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv >30 Min","41803981","CDM","983","RC","G0397","HCPCS","","","facility","both","","","","154.56","154.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brief Emotional/Behav Assmt","41803983","CDM","983","RC","96127","HCPCS","","","facility","both","","","","12.77","12.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annual Depression Screen,15 Mi","41803984","CDM","983","RC","G0444","HCPCS","","","facility","both","","","","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breath Hydrogen/Methane Test","41803987","CDM","983","RC","91065","HCPCS","","","facility","both","","","","211.27","211.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Grp","41803988","CDM","983","RC","G0109","HCPCS","","","facility","both","","","","37.33","37.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Single Les","41803991","CDM","983","RC","11102","HCPCS","","","facility","both","","","","255.56","255.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","41803993","CDM","983","RC","11104","HCPCS","","","facility","both","","","","321.88","321.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evaluate Pt Use Of Inhaler","41803994","CDM","983","RC","94664","HCPCS","","","facility","both","","","","44.27","44.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41803995","CDM","983","RC","99091","HCPCS","","","facility","both","","","","133.84","133.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mntr Physiol Param Setup","41803996","CDM","983","RC","99453","HCPCS","","","facility","both","","","","49.05","49.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Fulgrtn Urethral Caruncle","41803997","CDM","983","RC","53265","HCPCS","","","facility","both","","","","539.62","539.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us < 14 Wks Single Fetus","41803998","CDM","983","RC","76801","HCPCS","","","facility","both","","","","309.58","309.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us Limited 1+ Fetus(S)","41803999","CDM","983","RC","76815","HCPCS","","","facility","both","","","","213.23","213.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bilat Remove Impacted Ear Wax","41804000","CDM","983","RC","69210","HCPCS","","","facility","both","","","50","223.26","223.26","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"Video Visit Ppps, Initial Visi","41804001","CDM","983","RC","G0438","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ppps, Subseq Visit","41804002","CDM","983","RC","G0439","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Trans Care 14D/Dis","41804003","CDM","983","RC","99495","HCPCS","","","facility","both","","","95","450.07","450.07","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Trans Care 7D/Dis","41804004","CDM","983","RC","99496","HCPCS","","","facility","both","","","95","593.84","593.84","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","41804005","CDM","983","RC","99441","HCPCS","","","facility","both","","","","33.12","33.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41804007","CDM","983","RC","99443","HCPCS","","","facility","both","","","","94.41","94.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41804008","CDM","983","RC","99442","HCPCS","","","facility","both","","","","64.6","64.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Adv Care 30 Min","41804009","CDM","983","RC","99497","HCPCS","","","facility","both","","","95","200.19","200.19","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care Plan 30M","41804010","CDM","983","RC","99498","HCPCS","","","facility","both","","","95","169.56","169.56","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alcohol Misuse 15M","41804011","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41804012","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41804013","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41804015","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","35.95","35.95","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41804016","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","67.14","67.14","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41804017","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","83.78","83.78","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41804018","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","154.56","154.56","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41804019","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev New Pt Under 1 Yr","41804020","CDM","983","RC","99381","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 1-4 Yrs","41804021","CDM","983","RC","99382","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 5-11 Yrs","41804023","CDM","983","RC","99383","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 12-17 Yr","41804024","CDM","983","RC","99384","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 18-39 Yr","41804025","CDM","983","RC","99385","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 40-64 Yr","41804026","CDM","983","RC","99386","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev New Pt Over 65 Yrs","41804027","CDM","983","RC","99387","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev Est Pt Under 1 Yr","41804028","CDM","983","RC","99391","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 1-4 Yr","41804029","CDM","983","RC","99392","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 5-11Yr","41804031","CDM","983","RC","99393","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 12-17 Yr","41804032","CDM","983","RC","99394","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 18-39 Yr","41804033","CDM","983","RC","99395","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 40-64 Yr","41804034","CDM","983","RC","99396","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 65>","41804035","CDM","983","RC","99397","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Online Digital E M 5 10 Mins","41804036","CDM","983","RC","99421","HCPCS","","","facility","both","","","","34.96","34.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41804037","CDM","983","RC","99422","HCPCS","","","facility","both","","","","69.36","69.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41804038","CDM","983","RC","99423","HCPCS","","","facility","both","","","","112.27","112.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 7.0%<8.0%","41804039","CDM","983","RC","3051F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 8.0%","41804040","CDM","983","RC","3052F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Fluarix 0.5Ml","41804041","CDM","999","RC","90686","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Flumist Nasal Spray","41804042","CDM","999","RC","90672","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Cl Tx Phal Fx Fgr Thb Wo Manip","41804043","CDM","983","RC","26750","HCPCS","","","facility","both","","","","445.6","445.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sars-Cov-2 Covid19 W/Optic","41804044","CDM","983","RC","87811","HCPCS","","","facility","both","","","","107.12","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Inf A B Amp Prb","41804045","CDM","983","RC","87636","HCPCS","","","facility","both","","","","214.24","214.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Inf A B Rsv Amp Prb","41804046","CDM","983","RC","87637","HCPCS","","","facility","both","","","","321.36","321.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Eval Pt Use/Inhalr","41804047","CDM","983","RC","94664","HCPCS","","","facility","both","","","95","44.27","44.27","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Developmntl Scrn W/Score","41804049","CDM","983","RC","96110","HCPCS","","","facility","both","","","95","26.14","26.14","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Devel Tst Phy/Qhp 1St Hr","41804050","CDM","983","RC","96112","HCPCS","","","facility","both","","","95","313.12","313.12","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Brief Emotion/Bhav Assmt","41804051","CDM","983","RC","96127","HCPCS","","","facility","both","","","95","12.77","12.77","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Admin Hepatitis B Vaccine","41804052","CDM","983","RC","G0010","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41804053","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","69.44","69.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/ Retinopathy","41804054","CDM","983","RC","2022F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/O Retinopathy","41804056","CDM","983","RC","2023F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foreskin Manipulation","41804057","CDM","983","RC","54450","HCPCS","","","facility","both","","","","152.89","152.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Intranasal Office Proc","41804058","CDM","983","RC","30300","HCPCS","","","facility","both","","","","530.57","530.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immune Admin Oral/Nasal Addl","41804059","CDM","983","RC","90474","HCPCS","","","facility","both","","","","29.79","29.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Vaxelis Vacc","41804060","CDM","999","RC","90697","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Eye Img Valid Evc Retinopathy","41804062","CDM","983","RC","2026F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eye Img Valid W/O Retinopathy","41804064","CDM","983","RC","2033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Functional Status Assessed","41804065","CDM","983","RC","1170F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rvw All Meds By Rx/Dr In Rcrd","41804066","CDM","983","RC","1160F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc < 3 Cm","41804070","CDM","983","RC","21930","HCPCS","","","facility","both","","","","1199.95","1199.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Recertification Hha Pt","41804072","CDM","983","RC","G0179","HCPCS","","","facility","both","","","","96.68","96.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Certification Hha Patient","41804073","CDM","983","RC","G0180","HCPCS","","","facility","both","","","","123.85","123.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Health Care Supervision","41804074","CDM","983","RC","G0181","HCPCS","","","facility","both","","","","238.82","238.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pres/Absn Urine Incon Assess","41804075","CDM","983","RC","1090F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/L Xtremity Art 2 Levels","41804105","CDM","983","RC","93922","HCPCS","","","facility","both","","","","222.62","222.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Upr/L Xtremity Art 2 Levels","41804113","CDM","921","RC","93922","HCPCS","","","facility","both","","","TC","200","200","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
"Pf Upr/Lxtr Art Stdy 3+ Lvls","41804121","CDM","983","RC","93923","HCPCS","","","facility","both","","","","345.5","345.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1-2 Muscles","41804162","CDM","983","RC","20552","HCPCS","","","facility","both","","","","135.65","135.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Trigger Points 3/>","41804188","CDM","983","RC","20553","HCPCS","","","facility","both","","","","156.15","156.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Control Nasal Hemorrhage Simpl","41804220","CDM","983","RC","30901","HCPCS","","","facility","both","","","","361.78","361.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk 0.5Cm Or <","41804246","CDM","983","RC","11300","HCPCS","","","facility","both","","","","257.73","257.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","41804261","CDM","983","RC","10061","HCPCS","","","facility","both","","","","510.88","510.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx/Curett Of Cervix W/ Scope","41804287","CDM","983","RC","57454","HCPCS","","","facility","both","","","","389.63","389.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 1.1-2.0 Cm","41804402","CDM","983","RC","11312","HCPCS","","","facility","both","","","","401.56","401.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Nondystrophic Nails Any#","41804414","CDM","983","RC","11719","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk > 2.0 Cm","41804428","CDM","983","RC","11303","HCPCS","","","facility","both","","","","391.5","391.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Les Penis Cryosurgery","41804444","CDM","983","RC","54056","HCPCS","","","facility","both","","","","352.67","352.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Brn Sm","41804469","CDM","983","RC","16020","HCPCS","","","facility","both","","","","206.21","206.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion Single","41804485","CDM","983","RC","11055","HCPCS","","","facility","both","","","","162.41","162.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evacuate Subungual Hematoma","41804527","CDM","983","RC","11740","HCPCS","","","facility","both","","","","137.26","137.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debride Burn, Large","41804543","CDM","983","RC","16030","HCPCS","","","facility","both","","","","472.93","472.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exam/Bx Of Vag W/ Scope","41804576","CDM","983","RC","57421","HCPCS","","","facility","both","","","","407.26","407.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Cervix W/ Scope","41804600","CDM","983","RC","57455","HCPCS","","","facility","both","","","","372.96","372.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Bladder Catheter","41804626","CDM","983","RC","51701","HCPCS","","","facility","both","","","","109.28","109.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Dstl Rdl Fx Wo Mnp","41804642","CDM","983","RC","25600","HCPCS","","","facility","both","","","","831.58","831.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision, Clamp Newborn","41804675","CDM","983","RC","54150","HCPCS","","","facility","both","","","","374.16","374.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Tray Urimeter","41804758","CDM","272","RC","","","","","facility","both","","","","240.83","240.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Iud","41804774","CDM","983","RC","58300","HCPCS","","","facility","both","","","","193.29","193.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Iud","41804790","CDM","983","RC","58301","HCPCS","","","facility","both","","","","245.78","245.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb Ext Eye Conjunctiva","41804808","CDM","983","RC","65205","HCPCS","","","facility","both","","","","91.98","91.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Hemorrhoid Clot","41804824","CDM","983","RC","46320","HCPCS","","","facility","both","","","","495.95","495.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemical Cautery, Tissue","41804840","CDM","983","RC","17250","HCPCS","","","facility","both","","","","217.49","217.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion 2-4","41804865","CDM","983","RC","11056","HCPCS","","","facility","both","","","","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck <0.5Cm","41804881","CDM","983","RC","11305","HCPCS","","","facility","both","","","","267.59","267.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision Other Than Clamp","41804907","CDM","983","RC","54160","HCPCS","","","facility","both","","","","542.48","542.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg - Technical Fee","41804923","CDM","730","RC","93005","HCPCS","","","facility","both","","","","25","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp <0.5Cm","41804931","CDM","983","RC","11420","HCPCS","","","facility","both","","","","320.29","320.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 1.1-2.0Cm","41804956","CDM","983","RC","11402","HCPCS","","","facility","both","","","","426.11","426.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 0.6-1C","41804972","CDM","983","RC","11421","HCPCS","","","facility","both","","","","398.69","398.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 0.5Cm/<","41804998","CDM","983","RC","11400","HCPCS","","","facility","both","","","","319.55","319.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smiple Repair Wnd 2.5Cm","41805011","CDM","983","RC","12001","HCPCS","","","facility","both","","","","223.67","223.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 0.6-1.0Cm","41805037","CDM","983","RC","11401","HCPCS","","","facility","both","","","","385.43","385.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Breast Lesion","41805052","CDM","983","RC","19120","HCPCS","","","facility","both","","","","1207.1","1207.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Report","41805078","CDM","983","RC","","","","","facility","both","","","","23.26","23.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ben Les Trunk 3.1-4.0 Cm","41805086","CDM","983","RC","11404","HCPCS","","","facility","both","","","","550","550","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Complex S A L 1.1-2.5Cm","41805102","CDM","983","RC","13120","HCPCS","","","facility","both","","","","892.62","892.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endocervical Curettage","41805128","CDM","983","RC","57505","HCPCS","","","facility","both","","","","322.12","322.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry","41805144","CDM","460","RC","94010","HCPCS","","","facility","both","","","","82","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry Pre And Post","41805151","CDM","460","RC","94060","HCPCS","","","facility","both","","","","138","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Carp/Metacarp Dis","41805185","CDM","983","RC","26670","HCPCS","","","facility","both","","","","837.18","837.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Elbow Dislc W/O Anes","41805201","CDM","983","RC","24600","HCPCS","","","facility","both","","","","895.87","895.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comfor Knee Immobilizer Univ24","41805227","CDM","271","RC","","","","","facility","both","","","","59.65","59.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Humrl Shft Fx Wo Mnp","41805243","CDM","983","RC","24500","HCPCS","","","facility","both","","","","887.7","887.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk >4.0Cm","41805268","CDM","983","RC","11606","HCPCS","","","facility","both","","","","1094","1094","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate/Inj Ganglion Cyst","41805284","CDM","983","RC","20612","HCPCS","","","facility","both","","","","151.22","151.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb External Ear","41805300","CDM","983","RC","69200","HCPCS","","","facility","both","","","","201.41","201.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy Of Cervix","41805334","CDM","983","RC","57452","HCPCS","","","facility","both","","","","290.6","290.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shields Brace","41805342","CDM","271","RC","","","","","facility","both","","","","241.22","241.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath","41805350","CDM","983","RC","51702","HCPCS","","","facility","both","","","","154.38","154.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem Add 20 Cm/<","41805376","CDM","983","RC","97598","HCPCS","","","facility","both","","","","113.32","113.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Latex Free Volley Tennis Elbow","41805424","CDM","270","RC","","","","","facility","both","","","","80.46","80.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc Rem Fb Sq Comp","41805474","CDM","983","RC","10121","HCPCS","","","facility","both","","","","671.68","671.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 3.1-4C","41805598","CDM","983","RC","11604","HCPCS","","","facility","both","","","","776.33","776.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rpr Lac Cplx Forehd 1-2.5Cm","41805622","CDM","983","RC","13131","HCPCS","","","facility","both","","","","974.07","974.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Appl Cast Leg Short Walk","41805648","CDM","983","RC","29425","HCPCS","","","facility","both","","","","187.56","187.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Initial Visit","41805656","CDM","983","RC","G0438","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Subseq Visit","41805664","CDM","983","RC","G0439","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","41805670","CDM","983","RC","97597","HCPCS","","","facility","both","","","","245.41","245.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Face-Mm B9+Marg 3.1-4 C","41805696","CDM","983","RC","11444","HCPCS","","","facility","both","","","","692.88","692.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Ca Screening Dre","41808889","CDM","983","RC","G0102","HCPCS","","","facility","both","","","","57.72","57.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Preventive Exam","41808905","CDM","983","RC","G0402","HCPCS","","","facility","both","","","","398.34","398.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41808921","CDM","983","RC","G0403","HCPCS","","","facility","both","","","","41.86","41.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41808939","CDM","983","RC","G0405","HCPCS","","","facility","both","","","","19.53","19.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","41808955","CDM","983","RC","99407","HCPCS","","","facility","both","","","","67.14","67.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","41808971","CDM","983","RC","99406","HCPCS","","","facility","both","","","","35.95","35.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Done W/ Colposcopy Addon","41808997","CDM","983","RC","58110","HCPCS","","","facility","both","","","","119.69","119.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Int Rep","41809005","CDM","985","RC","93010","HCPCS","","","facility","both","","","","19.53","19.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Throm Hemorrhoid","41809302","CDM","983","RC","46083","HCPCS","","","facility","both","","","","487.23","487.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Tongue Les Wo Closure","41809348","CDM","983","RC","41110","HCPCS","","","facility","both","","","","562.48","562.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Paste/Unna Boot","41809807","CDM","983","RC","29580","HCPCS","","","facility","both","","","","158.11","158.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Intralesional >7","41809823","CDM","983","RC","11901","HCPCS","","","facility","both","","","","169.64","169.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obtaining Screen Pap","41809857","CDM","983","RC","Q0091","HCPCS","","","facility","both","","","","107.68","107.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ca Scn Pelvic/Breast Exam","41809871","CDM","983","RC","G0101","HCPCS","","","facility","both","","","","95.77","95.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Nursemaid Elbow","41809897","CDM","983","RC","24640","HCPCS","","","facility","both","","","","250.1","250.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iud Paragard","41809905","CDM","250","RC","J7300","HCPCS","","","facility","both","","","","1009.4","1009.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Svc Req For Power Mobility","41809913","CDM","983","RC","G0372","HCPCS","","","facility","both","","","","21.44","21.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cervical Polyectomy","41809940","CDM","983","RC","58558","HCPCS","","","facility","both","","","","3674.85","3674.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Into Skin Lesions =<7","41809941","CDM","983","RC","11900","HCPCS","","","facility","both","","","","137.44","137.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Audiometry Bekesy Screen","41809942","CDM","983","RC","92700","HCPCS","","","facility","both","","","","21.93","21.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","41809943","CDM","983","RC","11042","HCPCS","","","facility","both","","","","317.16","317.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Circum 28 Days Or Older","41809944","CDM","983","RC","54161","HCPCS","","","facility","both","","","","464.84","464.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Canalith Repositioning Proc","41809947","CDM","983","RC","95992","HCPCS","","","facility","both","","","","106.01","106.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 11-20 Min","41809949","CDM","960","RC","99442","HCPCS","","","facility","both","","","","64.6","64.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 21-30 Min","41809950","CDM","960","RC","99443","HCPCS","","","facility","both","","","","94.41","94.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Flap Trunk","41809951","CDM","983","RC","15734","HCPCS","","","facility","both","","","","3508.47","3508.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressng Chg Not For Burn","41809952","CDM","983","RC","15852","HCPCS","","","facility","both","","","","106.17","106.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41809953","CDM","983","RC","G0108","HCPCS","","","facility","both","","","","133.14","133.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immune Admin Oral/Nasal 1 Vacc","41809954","CDM","983","RC","90473","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
".Preventive Counseling 15 Min","41809955","CDM","983","RC","99401","HCPCS","","","facility","both","","","","39.28","39.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Psych Diag Eval W/Med Serv","41809956","CDM","983","RC","90792","HCPCS","","","facility","both","","","","366.06","366.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sc <2 Cm","41809960","CDM","983","RC","21011","HCPCS","","","facility","both","","","","908.91","908.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behavior Counsel Obesity 15M","41809961","CDM","983","RC","G0447","HCPCS","","","facility","both","","","","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Nutrician Therapy Ea 15Mi","41809962","CDM","983","RC","97802","HCPCS","","","facility","both","","","","91.32","91.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Hep A -Havrix","41809964","CDM","999","RC","90633","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Act Hib","41809965","CDM","999","RC","90648","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Hpv-Gardasil9 Or Cervarix","41809966","CDM","999","RC","90651","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Rotavirus-Rotarix Or Rata","41809967","CDM","999","RC","90681","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Pneumococcal Conjugate-Pr","41809968","CDM","999","RC","90670","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Ipv-Kinrix","41809969","CDM","999","RC","90696","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Hib/Polio-Pentacil","41809970","CDM","999","RC","90698","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Hib/Polio-Pentacil","41809971","CDM","999","RC","90698","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap-Infanrix","41809972","CDM","999","RC","90700","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Mmr-Mmrii","41809973","CDM","999","RC","90707","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Mmr-V-Proquad","41809974","CDM","999","RC","90710","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Ipv Ipol","41809975","CDM","999","RC","90713","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Tdap-Boostrix Or Adacel","41809976","CDM","999","RC","90715","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Varicella-Varivax","41809977","CDM","999","RC","90716","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Hep B/Polio-Pediarix","41809978","CDM","999","RC","90723","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Meninggococcal Conjugate-","41809979","CDM","999","RC","90734","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Hep B-Energix B","41809980","CDM","999","RC","90744","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Immune Admin Oral/Nasal 1 Vacc","41809981","CDM","983","RC","90473","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Entropion Suture","41809983","CDM","983","RC","67921","HCPCS","","","facility","both","","","","1204.46","1204.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reassess Nutrition Ther Ea 15M","41809985","CDM","983","RC","97803","HCPCS","","","facility","both","","","","79.27","79.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Implant Superficial","41809986","CDM","983","RC","20670","HCPCS","","","facility","both","","","","903.93","903.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Add Les","41809987","CDM","983","RC","11105","HCPCS","","","facility","both","","","","147.21","147.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incisional Bx Skin Single Les","41809988","CDM","983","RC","11106","HCPCS","","","facility","both","","","","391.67","391.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Ea Add Les","41809989","CDM","983","RC","11107","HCPCS","","","facility","both","","","","177.98","177.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Assmt/Care Pln Pt Cog Imp","41809990","CDM","983","RC","99483","HCPCS","","","facility","both","","","","639.38","639.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Drug Implant","41809991","CDM","983","RC","11981","HCPCS","","","facility","both","","","","237.91","237.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Exam Of Head And Neck","41809992","CDM","983","RC","76536","HCPCS","","","facility","both","","","","61","61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Clin Depres Scrn F/U Doc","41809993","CDM","983","RC","G8431","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Sub Misuse Assess","41809994","CDM","983","RC","G2011","HCPCS","","","facility","both","","","","37.24","37.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Dep Neg, No Plan Reqd","41809995","CDM","983","RC","G8510","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Pneumococcal 20 Val","41809996","CDM","999","RC","90677","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Beyfortus 50Mg/0.5Ml","41809997","CDM","999","RC","90380","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Beyfortus 100Mg/1Ml","41809998","CDM","999","RC","90381","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Tte W/O Doppler Complete","41809999","CDM","983","RC","93307","HCPCS","","","facility","both","","","","344.16","344.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Fluzone 0.5Ml Trivalent","41810001","CDM","999","RC","90656","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Flumist Nasal Trivalent","41810002","CDM","999","RC","90660","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Covid Mod 12Y+ 0.5Ml","41810004","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Pf Circum 28 Days Or Older","41810006","CDM","983","RC","54161","HCPCS","","","facility","both","","","","464.84","464.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Canalith Repositioning Proc","41810008","CDM","983","RC","95992","HCPCS","","","facility","both","","","","106.01","106.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Audiometry Puretone Screen","41810009","CDM","983","RC","92551","HCPCS","","","facility","both","","","","35.79","35.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 5-10 Min","41810010","CDM","960","RC","99441","HCPCS","","","facility","both","","","","33.12","33.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 11-20 Min","41810012","CDM","960","RC","99442","HCPCS","","","facility","both","","","","64.6","64.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 21-30 Min","41810016","CDM","960","RC","99443","HCPCS","","","facility","both","","","","94.41","94.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostatic Microware Thermotx","41810017","CDM","983","RC","53850","HCPCS","","","facility","both","","","","4107.06","4107.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stress Test W/Si&R","41810018","CDM","983","RC","93015","HCPCS","","","facility","both","","","","176.27","176.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Destroy Lesion Of Lid Margi","41810020","CDM","983","RC","67850","HCPCS","","","facility","both","","","","548.02","548.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Event Recorder","41810023","CDM","983","RC","93268","HCPCS","","","facility","both","","","","527.48","527.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Covid Mod 6M-11Y 0.25Ml","41810024","CDM","999","RC","91321","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Trans Care Mgmt 14 Day Disc","41810025","CDM","983","RC","99495","HCPCS","","","facility","both","","","","450.07","450.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Trans Care Mgmt 7 Day Disch","41810027","CDM","983","RC","99496","HCPCS","","","facility","both","","","","593.84","593.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rem Contraceptive Cap","41810031","CDM","983","RC","11976","HCPCS","","","facility","both","","","","350.49","350.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rem Foreign Body Foot","41810033","CDM","983","RC","28190","HCPCS","","","facility","both","","","","648.65","648.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snellen Eye Test","41810035","CDM","983","RC","99173","HCPCS","","","facility","both","","","","18.91","18.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41810048","CDM","983","RC","96372","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/O Imaging","41810054","CDM","983","RC","32554","HCPCS","","","facility","both","","","","563.22","563.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","41810055","CDM","983","RC","32555","HCPCS","","","facility","both","","","","796.4","796.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occular Instrumnt Screen Bil","41810062","CDM","983","RC","99174","HCPCS","","","facility","both","","","","86.96","86.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hydration Iv Infusion Init","41810064","CDM","983","RC","96360","HCPCS","","","facility","both","","","","87.67","87.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Grp","41810065","CDM","983","RC","G0109","HCPCS","","","facility","both","","","","37.33","37.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reassess Nutrition Ther Ea 15M","41810067","CDM","983","RC","97803","HCPCS","","","facility","both","","","","79.27","79.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41810070","CDM","983","RC","90472","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Init","41810073","CDM","983","RC","96365","HCPCS","","","facility","both","","","","184.51","184.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Iv Inf Add-On","41810075","CDM","983","RC","96366","HCPCS","","","facility","both","","","","54.69","54.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Hep B-Comvax","41810096","CDM","999","RC","90748","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Pf Rem Fb Coneal W Slit Lamp","41810098","CDM","983","RC","65222","HCPCS","","","facility","both","","","","167.54","167.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Postpartum Care","41810100","CDM","983","RC","59430","HCPCS","","","facility","both","","","","491.91","491.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wnd Prep Trk/Arm/Leg 100Sq Cm","41810101","CDM","983","RC","15002","HCPCS","","","facility","both","","","","860.85","860.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystoscopy","41810105","CDM","983","RC","52000","HCPCS","","","facility","both","","","","536.12","536.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Eye Exam W/Photo","41810106","CDM","983","RC","92250","HCPCS","","","facility","both","","","","113.51","113.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx <=50Sqcm","41810107","CDM","983","RC","97605","HCPCS","","","facility","both","","","","108.19","108.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route 1St","41810113","CDM","983","RC","90460","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route Ea Ad","41810115","CDM","983","RC","90461","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Ionized Calcium (Ca)","41810120","CDM","301","RC","82330","HCPCS","","","facility","both","","","QW","25","25","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Potassium (K)","41810121","CDM","301","RC","84132","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Sodium (Na)","41810123","CDM","301","RC","84295","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Creatinine (Crea)","41810124","CDM","301","RC","82565","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Urea","41810125","CDM","301","RC","84520","HCPCS","","","facility","both","","","QW","7","7","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Flu","41810126","CDM","300","RC","87804","HCPCS","","","facility","both","","","QW","34","34","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hematocrit (Hct)","41810127","CDM","305","RC","85014","HCPCS","","","facility","both","","","QW","5","5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Chloride (Cl)","41810129","CDM","301","RC","82435","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hemoglobin (Hb)","41810130","CDM","305","RC","85018","HCPCS","","","facility","both","","","QW","5","5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Basic Metabolic Poanel","41810131","CDM","301","RC","80047","HCPCS","","","facility","both","","","QW","25","25","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Rsv","41810132","CDM","306","RC","87807","HCPCS","","","facility","both","","","QW","24","24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Tco2","41810133","CDM","301","RC","82374","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Diast Bp < 80 Mm Hg","41810137","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41810138","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41810139","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41810140","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41810141","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chron Care Mgmt Srvc 20 Min","41810142","CDM","983","RC","99490","HCPCS","","","facility","both","","","","98.76","98.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Hematocrit (Hct)","41810217","CDM","305","RC","85014","HCPCS","","","facility","both","","","QW","5","5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Blood Lead","41810221","CDM","300","RC","83655","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Upr/L Xtremity Art 2 Levels","41811589","CDM","921","RC","93922","HCPCS","","","facility","both","","","TC","200","200","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
"Immune Admin Oral/Nasal 1 Vacc","41811592","CDM","983","RC","90473","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Global","41811606","CDM","983","RC","93000","HCPCS","","","facility","both","","","","41.86","41.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Developmental Screen W/Score","41811607","CDM","983","RC","96110","HCPCS","","","facility","both","","","","26.14","26.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Absc Smpl Or Sgl","41811613","CDM","983","RC","10060","HCPCS","","","facility","both","","","","300.72","300.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","41811621","CDM","983","RC","10061","HCPCS","","","facility","both","","","","510.88","510.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Simple","41811639","CDM","983","RC","10120","HCPCS","","","facility","both","","","","383.78","383.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","41811647","CDM","983","RC","10140","HCPCS","","","facility","both","","","","424.11","424.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","41811654","CDM","983","RC","10160","HCPCS","","","facility","both","","","","324.82","324.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Ext Eczema/Infect Skin","41811662","CDM","983","RC","11000","HCPCS","","","facility","both","","","","140.33","140.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion Single","41811670","CDM","983","RC","11055","HCPCS","","","facility","both","","","","162.41","162.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion 2-4","41811688","CDM","983","RC","11056","HCPCS","","","facility","both","","","","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Skin Tags 15 Lesions","41811712","CDM","983","RC","11200","HCPCS","","","facility","both","","","","221.82","221.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Tags Ea Add'l 10","41811720","CDM","983","RC","11201","HCPCS","","","facility","both","","","","44.08","44.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk 0.5Cm Or <","41811738","CDM","983","RC","11300","HCPCS","","","facility","both","","","","257.73","257.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 0.6-1Cm","41811746","CDM","983","RC","11301","HCPCS","","","facility","both","","","","309.27","309.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 1.1-2Cm","41811753","CDM","983","RC","11302","HCPCS","","","facility","both","","","","357.18","357.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk > 2.0 Cm","41811761","CDM","983","RC","11303","HCPCS","","","facility","both","","","","391.5","391.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck <0.5Cm","41811779","CDM","983","RC","11305","HCPCS","","","facility","both","","","","267.59","267.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck .6-1Cm","41811787","CDM","983","RC","11306","HCPCS","","","facility","both","","","","313.06","313.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 0.5Cm Or <","41811795","CDM","983","RC","11310","HCPCS","","","facility","both","","","","295.63","295.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Face 0.6-1.0 Cm","41811803","CDM","983","RC","11311","HCPCS","","","facility","both","","","","347.77","347.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 1.1-2.0 Cm","41811811","CDM","983","RC","11312","HCPCS","","","facility","both","","","","401.56","401.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 0.5Cm/<","41811829","CDM","983","RC","11400","HCPCS","","","facility","both","","","","319.55","319.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 0.6-1.0Cm","41811837","CDM","983","RC","11401","HCPCS","","","facility","both","","","","385.43","385.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 1.1-2.0Cm","41811845","CDM","983","RC","11402","HCPCS","","","facility","both","","","","426.11","426.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Facility Care Lvl Iii","41811847","CDM","983","RC","99306","HCPCS","","","facility","both","","","","388.31","388.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subs Lvl Iii","41811848","CDM","983","RC","99309","HCPCS","","","facility","both","","","","214.65","214.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl Iv","41811849","CDM","983","RC","99310","HCPCS","","","facility","both","","","","315.65","315.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Snf Discharge Day 30 Min","41811850","CDM","983","RC","99316","HCPCS","","","facility","both","","","","245.92","245.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Trunk 2.1-3C","41811852","CDM","983","RC","11403","HCPCS","","","facility","both","","","","486","486","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41811855","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41811856","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41811857","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41811858","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ben Les Trunk 3.1-4.0 Cm","41811860","CDM","983","RC","11404","HCPCS","","","facility","both","","","","550","550","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41811861","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41811862","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41811863","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41811864","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41811865","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41811866","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41811867","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41811868","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screening For Depression","41811869","CDM","983","RC","3725F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41811870","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41811871","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41811872","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41811873","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41811874","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41811875","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Falls Assess-Docd Le1/Yr","41811876","CDM","983","RC","1101F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41811877","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk >4 Cm","41811878","CDM","983","RC","11406","HCPCS","","","facility","both","","","","770.4","770.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Falls Assess-Docd Ge2+/Yr","41811879","CDM","983","RC","1100F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt-Focused Hlth Risk Assmt","41811880","CDM","983","RC","96160","HCPCS","","","facility","both","","","","6.67","6.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Caregiver Health Risk Assmt","41811881","CDM","983","RC","96161","HCPCS","","","facility","both","","","","6.67","6.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Complex","41811882","CDM","983","RC","95972","HCPCS","","","facility","both","","","","136.23","136.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Flu Virus Vaccine","41811883","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","84","84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol Misuse Scrn 15 Min Yr","41811884","CDM","983","RC","G0442","HCPCS","","","facility","both","","","","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit To Determ Ldct Elig","41811885","CDM","983","RC","G0296","HCPCS","","","facility","both","","","","67.77","67.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp <0.5Cm","41811886","CDM","983","RC","11420","HCPCS","","","facility","both","","","","320.29","320.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dschrg Med/Current Med Merge","41811887","CDM","983","RC","1111F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advance Care Planning Tlk Doc","41811888","CDM","983","RC","1158F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C <100 Mg/Dl","41811889","CDM","983","RC","3048F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C 100 - 129 Mg/Dl","41811890","CDM","983","RC","3049F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldl-C >=130 Mg/Dl","41811891","CDM","983","RC","3050F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Microalbuminuria Rev","41811892","CDM","983","RC","3060F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Microalbuminuria Rev","41811893","CDM","983","RC","3061F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 0.6-1C","41811894","CDM","983","RC","11421","HCPCS","","","facility","both","","","","398.69","398.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Macroalbuminuria Rev","41811895","CDM","983","RC","3062F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephropathy Doc Tx","41811896","CDM","983","RC","3066F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Low Risk For Retinopathy","41811897","CDM","983","RC","3072F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Use Txmnt Counseling","41811898","CDM","983","RC","4000F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Use Txmnt Pharmacol","41811899","CDM","983","RC","4001F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pt Tobacco Screen Rcvd Tlk - 4","41811900","CDM","983","RC","4004F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ace/Arb Therapy Rxd/Taken","41811901","CDM","983","RC","4010F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc B9 Les S N Ex G 1.1-2.0Cm","41811902","CDM","983","RC","11422","HCPCS","","","facility","both","","","","446.71","446.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41811904","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41811905","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41811906","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41811907","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41811908","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","58.5","58.5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41811909","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","111.38","111.38","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Excise Ben Sk Les Scalp 2.1-3C","41811910","CDM","983","RC","11423","HCPCS","","","facility","both","","","","504.35","504.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Est Pt Level Iii","41811911","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","180.81","180.81","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41811912","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41811913","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","348.94","348.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41811914","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","232.29","232.29","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41811915","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","315.63","315.63","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41811916","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","465.37","465.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41811918","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41811919","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41811920","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41811921","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Bx Nail Unit","41811923","CDM","983","RC","11755","HCPCS","","","facility","both","","","","305.46","305.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","41811924","CDM","983","RC","99497","HCPCS","","","facility","both","","","","200.19","200.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ear Lavage Unilateral","41811925","CDM","983","RC","69209","HCPCS","","","facility","both","","","","37.6","37.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Pedvax Hib","41811927","CDM","999","RC","90647","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Excise Benign Lesion >4.0Cm","41811928","CDM","983","RC","11426","HCPCS","","","facility","both","","","","812.18","812.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Scrotum And Contents","41811929","CDM","983","RC","76870","HCPCS","","","facility","both","","","","269.72","269.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged Svcs W/O Contact","41811931","CDM","983","RC","99358","HCPCS","","","facility","both","","","","258.65","258.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroeltrd Stim Post Tibial","41811933","CDM","983","RC","64566","HCPCS","","","facility","both","","","","327.54","327.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Lesion Face <0.5Cm","41811936","CDM","983","RC","11440","HCPCS","","","facility","both","","","","355.27","355.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Flulaval 0.5Ml Inj","41811937","CDM","999","RC","90686","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Carpal Tunnel Tx Injection","41811941","CDM","983","RC","20526","HCPCS","","","facility","both","","","","189.95","189.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Drug Implant","41811942","CDM","983","RC","11981","HCPCS","","","facility","both","","","","250.91","250.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Othr Ben Les 0.6-1.0Cm","41811944","CDM","983","RC","11441","HCPCS","","","facility","both","","","","429.57","429.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Drug Implant","41811945","CDM","983","RC","11982","HCPCS","","","facility","both","","","","284.05","284.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Bl W/Cath Insertion","41811946","CDM","983","RC","51102","HCPCS","","","facility","both","","","","585.29","585.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv 15-30Min","41811949","CDM","983","RC","G0396","HCPCS","","","facility","both","","","","83.78","83.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Subs Interv >30 Min","41811950","CDM","983","RC","G0397","HCPCS","","","facility","both","","","","154.56","154.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 1.1-2Cm","41811951","CDM","983","RC","11442","HCPCS","","","facility","both","","","","475.18","475.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Annual Depression Screen,15 Mi","41811952","CDM","983","RC","G0444","HCPCS","","","facility","both","","","","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brief Emotional/Behav Assmt","41811953","CDM","983","RC","96127","HCPCS","","","facility","both","","","","12.77","12.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove W Ins Drug Implant","41811954","CDM","983","RC","11983","HCPCS","","","facility","both","","","","346.6","346.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Single Les","41811957","CDM","983","RC","11102","HCPCS","","","facility","both","","","","255.56","255.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evaluate Pt Use Of Inhaler","41811959","CDM","983","RC","94664","HCPCS","","","facility","both","","","","44.27","44.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41811960","CDM","983","RC","99091","HCPCS","","","facility","both","","","","133.84","133.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mntr Physiol Param Setup","41811961","CDM","983","RC","99453","HCPCS","","","facility","both","","","","49.05","49.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Fulgrtn Urethral Caruncle","41811965","CDM","983","RC","53265","HCPCS","","","facility","both","","","","539.62","539.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us < 14 Wks Single Fetus","41811966","CDM","983","RC","76801","HCPCS","","","facility","both","","","","309.58","309.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us Limited 1+ Fetus(S)","41811967","CDM","983","RC","76815","HCPCS","","","facility","both","","","","213.23","213.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Bartholins Gland Abscess","41811968","CDM","983","RC","56420","HCPCS","","","facility","both","","","","388.35","388.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 2.1-3Cm","41811969","CDM","983","RC","11443","HCPCS","","","facility","both","","","","558.51","558.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bilat Remove Impacted Ear Wax","41811970","CDM","983","RC","69210","HCPCS","","","facility","both","","","50","223.26","223.26","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"Video Visit Ppps, Initial Visi","41811971","CDM","983","RC","G0438","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ppps, Subseq Visit","41811972","CDM","983","RC","G0439","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Trans Care 14D/Dis","41811973","CDM","983","RC","99495","HCPCS","","","facility","both","","","95","450.07","450.07","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Trans Care 7D/Dis","41811974","CDM","983","RC","99496","HCPCS","","","facility","both","","","95","593.84","593.84","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","41811975","CDM","983","RC","99441","HCPCS","","","facility","both","","","","33.12","33.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41811976","CDM","983","RC","99442","HCPCS","","","facility","both","","","","64.6","64.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.5Cm<","41811977","CDM","983","RC","11600","HCPCS","","","facility","both","","","","496.42","496.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41811978","CDM","983","RC","99443","HCPCS","","","facility","both","","","","94.41","94.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Adv Care 30 Min","41811979","CDM","983","RC","99497","HCPCS","","","facility","both","","","95","200.19","200.19","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care Plan 30M","41811980","CDM","983","RC","99498","HCPCS","","","facility","both","","","95","169.56","169.56","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alcohol Misuse 15M","41811981","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41811982","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41811983","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","45.16","45.16","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41811984","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","35.95","35.95","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Excise Mal Sk Les Trunk 0.6-1C","41811985","CDM","983","RC","11601","HCPCS","","","facility","both","","","","573.73","573.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Behav Smoking>10","41811986","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","67.14","67.14","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41811987","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","83.78","83.78","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41811988","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","154.56","154.56","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41811989","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev New Pt Under 1 Yr","41811990","CDM","983","RC","99381","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 1-4 Yrs","41811991","CDM","983","RC","99382","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 5-11 Yrs","41811992","CDM","983","RC","99383","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Excise Mal Sk Les Trunk 1.1-2C","41811993","CDM","983","RC","11602","HCPCS","","","facility","both","","","","618.19","618.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Vst Prev New Pt 12-17 Yr","41811994","CDM","983","RC","99384","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 18-39 Yr","41811995","CDM","983","RC","99385","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev New Pt 40-64 Yr","41811996","CDM","983","RC","99386","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev New Pt Over 65 Yrs","41811997","CDM","983","RC","99387","HCPCS","","","facility","both","","","95","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Prev Est Pt Under 1 Yr","41811998","CDM","983","RC","99391","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 1-4 Yr","41811999","CDM","983","RC","99392","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 5-11Yr","41812000","CDM","983","RC","99393","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 12-17 Yr","41812001","CDM","983","RC","99394","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 18-39 Yr","41812002","CDM","983","RC","99395","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Vst Prev Est Pt 40-64 Yr","41812003","CDM","983","RC","99396","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Prev Est Pt 65>","41812004","CDM","983","RC","99397","HCPCS","","","facility","both","","","95","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Online Digital E M 5 10 Mins","41812005","CDM","983","RC","99421","HCPCS","","","facility","both","","","","34.96","34.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41812006","CDM","983","RC","99422","HCPCS","","","facility","both","","","","69.36","69.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41812007","CDM","983","RC","99423","HCPCS","","","facility","both","","","","112.27","112.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 7.0%<8.0%","41812008","CDM","983","RC","3051F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 2.1-3C","41812009","CDM","983","RC","11603","HCPCS","","","facility","both","","","","698.61","698.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 8.0%","41812010","CDM","983","RC","3052F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Nondystrophic Nails Any#","41812011","CDM","983","RC","11719","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Fluarix 0.5Ml","41812012","CDM","999","RC","90686","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Flumist Nasal Spray","41812013","CDM","999","RC","90672","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"I D Pilonidal Cyst Simple","41812014","CDM","983","RC","10080","HCPCS","","","facility","both","","","","540.59","540.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sars-Cov-2 Covid19 W/Optic","41812015","CDM","983","RC","87811","HCPCS","","","facility","both","","","","107.12","107.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Inf A B Amp Prb","41812016","CDM","983","RC","87636","HCPCS","","","facility","both","","","","214.24","214.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.5Cm<","41812017","CDM","983","RC","11620","HCPCS","","","facility","both","","","","498.54","498.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sarscov2 Inf A B Rsv Amp Prb","41812018","CDM","983","RC","87637","HCPCS","","","facility","both","","","","321.36","321.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Eval Pt Use/Inhalr","41812019","CDM","983","RC","94664","HCPCS","","","facility","both","","","95","44.27","44.27","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Developmntl Scrn W/Score","41812020","CDM","983","RC","96110","HCPCS","","","facility","both","","","95","26.14","26.14","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Devel Tst Phy/Qhp 1St Hr","41812021","CDM","983","RC","96112","HCPCS","","","facility","both","","","95","313.12","313.12","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Brief Emotion/Bhav Assmt","41812022","CDM","983","RC","96127","HCPCS","","","facility","both","","","95","12.77","12.77","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Admin Hepatitis B Vaccine","41812023","CDM","983","RC","G0010","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41812024","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","69.44","69.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.6-1C","41812025","CDM","983","RC","11621","HCPCS","","","facility","both","","","","575.83","575.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/ Retinopathy","41812026","CDM","983","RC","2022F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/O Retinopathy","41812027","CDM","983","RC","2023F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","41812028","CDM","983","RC","11104","HCPCS","","","facility","both","","","","321.88","321.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immune Admin Oral/Nasal Addl","41812029","CDM","983","RC","90474","HCPCS","","","facility","both","","","","29.79","29.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Vaxelis Vacc","41812030","CDM","999","RC","90697","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Eye Img Valid Evc Retinopathy","41812032","CDM","983","RC","2026F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 1.1-2C","41812033","CDM","983","RC","11622","HCPCS","","","facility","both","","","","636.66","636.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eye Img Valid W/O Retinopathy","41812034","CDM","983","RC","2033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Neck Les Sc < 3 Cm","41812035","CDM","983","RC","21555","HCPCS","","","facility","both","","","","1047.59","1047.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sc <2 Cm","41812036","CDM","983","RC","21011","HCPCS","","","facility","both","","","","908.91","908.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Shoulder Les Sc < 3 Cm","41812037","CDM","983","RC","23075","HCPCS","","","facility","both","","","","1265.83","1265.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Functional Status Assessed","41812038","CDM","983","RC","1170F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rvw All Meds By Rx/Dr In Rcrd","41812039","CDM","983","RC","1160F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 2.1-3C","41812041","CDM","983","RC","11623","HCPCS","","","facility","both","","","","739.35","739.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc < 3 Cm","41812044","CDM","983","RC","21930","HCPCS","","","facility","both","","","","1199.95","1199.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Recertification Hha Pt","41812045","CDM","983","RC","G0179","HCPCS","","","facility","both","","","","96.68","96.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Certification Hha Patient","41812046","CDM","983","RC","G0180","HCPCS","","","facility","both","","","","123.85","123.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Health Care Supervision","41812047","CDM","983","RC","G0181","HCPCS","","","facility","both","","","","238.82","238.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 0.5Cm <","41812058","CDM","983","RC","11640","HCPCS","","","facility","both","","","","511.04","511.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Lesion Face 0.6-1Cm","41812066","CDM","983","RC","11641","HCPCS","","","facility","both","","","","595.73","595.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 1.1-2Cm","41812074","CDM","983","RC","11642","HCPCS","","","facility","both","","","","672.28","672.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 2.1-3Cm","41812082","CDM","983","RC","11643","HCPCS","","","facility","both","","","","782.88","782.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails 1-5","41812090","CDM","983","RC","11720","HCPCS","","","facility","both","","","","81.76","81.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails >6","41812108","CDM","983","RC","11721","HCPCS","","","facility","both","","","","111.34","111.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simpl Avulsion Nail Plt Single","41812116","CDM","983","RC","11730","HCPCS","","","facility","both","","","","277.23","277.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avulsion Nail Ea 2+","41812124","CDM","983","RC","11732","HCPCS","","","facility","both","","","","82.69","82.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evacuate Subungual Hematoma","41812132","CDM","983","RC","11740","HCPCS","","","facility","both","","","","137.26","137.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Nail/Matrix Perm Remove","41812140","CDM","983","RC","11750","HCPCS","","","facility","both","","","","391.83","391.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smiple Repair Wnd 2.5Cm","41812157","CDM","983","RC","12001","HCPCS","","","facility","both","","","","223.67","223.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Wnd 2.6-7.5 Cm","41812165","CDM","983","RC","12002","HCPCS","","","facility","both","","","","270","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 7.6-12.5Cm","41812173","CDM","983","RC","12004","HCPCS","","","facility","both","","","","312.73","312.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.5Cm Or <","41812181","CDM","983","RC","12011","HCPCS","","","facility","both","","","","270.79","270.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.6-5Cm","41812199","CDM","983","RC","12013","HCPCS","","","facility","both","","","","279.91","279.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 5.1-7.5Cm","41812207","CDM","983","RC","12014","HCPCS","","","facility","both","","","","338.42","338.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41812215","CDM","983","RC","12031","HCPCS","","","facility","both","","","","636.33","636.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Scalp 2.6-7.5Cm","41812223","CDM","983","RC","12032","HCPCS","","","facility","both","","","","762.78","762.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr S/Tr/Ext 7.6-12.5","41812231","CDM","983","RC","12034","HCPCS","","","facility","both","","","","809.19","809.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter N/H/F/G 2.5Cm Or<","41812249","CDM","983","RC","12041","HCPCS","","","facility","both","","","","636","636","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 2.6-7.5Cm","41812256","CDM","983","RC","12042","HCPCS","","","facility","both","","","","751.22","751.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 7.6-12.5Cm","41812264","CDM","983","RC","12044","HCPCS","","","facility","both","","","","932.46","932.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.5Cm Or <","41812272","CDM","983","RC","12051","HCPCS","","","facility","both","","","","683.2","683.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.6-5Cm","41812280","CDM","983","RC","12052","HCPCS","","","facility","both","","","","761.75","761.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 5.1-7.5Cm","41812298","CDM","983","RC","12053","HCPCS","","","facility","both","","","","893.73","893.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Complex S A L 1.1-2.5Cm","41812306","CDM","983","RC","13120","HCPCS","","","facility","both","","","","892.62","892.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Brn Sm","41812314","CDM","983","RC","16020","HCPCS","","","facility","both","","","","206.21","206.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debride Burn, Large","41812322","CDM","983","RC","16030","HCPCS","","","facility","both","","","","472.93","472.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion 1St","41812330","CDM","983","RC","17000","HCPCS","","","facility","both","","","","163.07","163.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct Skin Lesion Ea 2-14","41812348","CDM","983","RC","17003","HCPCS","","","facility","both","","","","15.57","15.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion >15","41812355","CDM","983","RC","17004","HCPCS","","","facility","both","","","","398.14","398.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct B9 Lesion 1-14","41812363","CDM","983","RC","17110","HCPCS","","","facility","both","","","","286.4","286.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Flat Warts >15","41812371","CDM","983","RC","17111","HCPCS","","","facility","both","","","","333.91","333.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemical Cautery, Tissue","41812389","CDM","983","RC","17250","HCPCS","","","facility","both","","","","217.49","217.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Breast Lesion","41812397","CDM","983","RC","19120","HCPCS","","","facility","both","","","","1207.1","1207.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Sheath","41812405","CDM","983","RC","20550","HCPCS","","","facility","both","","","","131.33","131.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1-2 Muscles","41812413","CDM","983","RC","20552","HCPCS","","","facility","both","","","","135.65","135.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Trigger Points 3/>","41812421","CDM","983","RC","20553","HCPCS","","","facility","both","","","","156.15","156.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis Small Joint","41812439","CDM","983","RC","20600","HCPCS","","","facility","both","","","","121.33","121.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Joint/Bursa W/O Us","41812447","CDM","983","RC","20605","HCPCS","","","facility","both","","","","125.78","125.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Major Joint W/O Us","41812454","CDM","983","RC","20610","HCPCS","","","facility","both","","","","148.94","148.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Dstl Rdl Fx Wo Mnp","41812462","CDM","983","RC","25600","HCPCS","","","facility","both","","","","831.58","831.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Carp/Metacarp Dis","41812470","CDM","983","RC","26670","HCPCS","","","facility","both","","","","837.18","837.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Leg Ankle Deep Absc Hema","41812488","CDM","983","RC","27603","HCPCS","","","facility","both","","","","1320.48","1320.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Arm","41812496","CDM","983","RC","29065","HCPCS","","","facility","both","","","","234.04","234.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Arm","41812504","CDM","983","RC","29075","HCPCS","","","facility","both","","","","211.69","211.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Gauntlet","41812512","CDM","983","RC","29085","HCPCS","","","facility","both","","","","232.72","232.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Arm","41812520","CDM","983","RC","29105","HCPCS","","","facility","both","","","","199.74","199.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Arm","41812538","CDM","983","RC","29125","HCPCS","","","facility","both","","","","160.23","160.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Finger","41812546","CDM","983","RC","29130","HCPCS","","","facility","both","","","","99.15","99.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Leg","41812553","CDM","983","RC","29345","HCPCS","","","facility","both","","","","328.65","328.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Leg","41812561","CDM","983","RC","29405","HCPCS","","","facility","both","","","","195.56","195.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Leg","41812579","CDM","983","RC","29505","HCPCS","","","facility","both","","","","212.26","212.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Leg","41812587","CDM","983","RC","29515","HCPCS","","","facility","both","","","","173.43","173.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Gauntlet,Boot,Body Cast","41812595","CDM","983","RC","29700","HCPCS","","","facility","both","","","","155.26","155.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Control Nasal Hemorrhage Simpl","41812603","CDM","983","RC","30901","HCPCS","","","facility","both","","","","361.78","361.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Tongue Les Wo Closure","41812615","CDM","983","RC","41110","HCPCS","","","facility","both","","","","562.48","562.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Throm Hemorrhoid","41812629","CDM","983","RC","46083","HCPCS","","","facility","both","","","","487.23","487.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Hemorrhoid Clot","41812637","CDM","983","RC","46320","HCPCS","","","facility","both","","","","495.95","495.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy Diagnostic","41812645","CDM","983","RC","46600","HCPCS","","","facility","both","","","","266.32","266.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Lesion","41812652","CDM","983","RC","46922","HCPCS","","","facility","both","","","","748.93","748.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Bladder Catheter","41812686","CDM","983","RC","51701","HCPCS","","","facility","both","","","","109.28","109.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Les Penis Cryosurgery","41812694","CDM","983","RC","54056","HCPCS","","","facility","both","","","","352.67","352.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision, Clamp Newborn","41812702","CDM","983","RC","54150","HCPCS","","","facility","both","","","","374.16","374.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision Other Than Clamp","41812710","CDM","983","RC","54160","HCPCS","","","facility","both","","","","542.48","542.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exam/Bx Of Vag W/ Scope","41812728","CDM","983","RC","57421","HCPCS","","","facility","both","","","","407.26","407.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx/Curett Of Cervix W/ Scope","41812736","CDM","983","RC","57454","HCPCS","","","facility","both","","","","389.63","389.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Cervix W/ Scope","41812744","CDM","983","RC","57455","HCPCS","","","facility","both","","","","372.96","372.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy/Excise Of Lesion Cervix","41812751","CDM","983","RC","57500","HCPCS","","","facility","both","","","","361.47","361.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endocervical Curettage","41812769","CDM","983","RC","57505","HCPCS","","","facility","both","","","","322.12","322.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endometrial Biopsy","41812777","CDM","983","RC","58100","HCPCS","","","facility","both","","","","236.26","236.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Iud","41812785","CDM","983","RC","58300","HCPCS","","","facility","both","","","","193.29","193.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Iud","41812793","CDM","983","RC","58301","HCPCS","","","facility","both","","","","245.78","245.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","41812801","CDM","983","RC","62270","HCPCS","","","facility","both","","","","349.54","349.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb Ext Eye Conjunctiva","41812819","CDM","983","RC","65205","HCPCS","","","facility","both","","","","91.98","91.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Impact Ear Wax W/Instr Uni","41812827","CDM","983","RC","69210","HCPCS","","","facility","both","","","","114.52","114.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41812828","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","18","18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Finger Stick","41812829","CDM","300","RC","36416","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tympanometry","41812835","CDM","983","RC","92567","HCPCS","","","facility","both","","","","39.1","39.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer","41812843","CDM","983","RC","94640","HCPCS","","","facility","both","","","","47.13","47.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 1-2 Body Regions","41812850","CDM","983","RC","98925","HCPCS","","","facility","both","","","","75.66","75.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 3-4 Body Regions","41812868","CDM","983","RC","98926","HCPCS","","","facility","both","","","","108.56","108.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 5-6 Body Regions","41812876","CDM","983","RC","98927","HCPCS","","","facility","both","","","","141.71","141.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 7-8 Body Regions","41812884","CDM","983","RC","98928","HCPCS","","","facility","both","","","","172.34","172.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 9-10 Body Regions","41812892","CDM","983","RC","98929","HCPCS","","","facility","both","","","","204.66","204.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41812918","CDM","983","RC","99202","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41812926","CDM","983","RC","99203","HCPCS","","","facility","both","","","","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41812934","CDM","983","RC","99204","HCPCS","","","facility","both","","","","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41812942","CDM","983","RC","99205","HCPCS","","","facility","both","","","","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41812959","CDM","983","RC","99211","HCPCS","","","facility","both","","","","58.5","58.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41812967","CDM","983","RC","99212","HCPCS","","","facility","both","","","","111.38","111.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41812975","CDM","983","RC","99213","HCPCS","","","facility","both","","","","180.81","180.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41812983","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41812991","CDM","983","RC","99215","HCPCS","","","facility","both","","","","348.94","348.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41813015","CDM","983","RC","99242","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41813023","CDM","983","RC","99243","HCPCS","","","facility","both","","","","258.32","258.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41813031","CDM","983","RC","99244","HCPCS","","","facility","both","","","","389.22","389.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41813049","CDM","983","RC","99245","HCPCS","","","facility","both","","","","490.01","490.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt Under 1 Yr","41813056","CDM","983","RC","99381","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 1-4 Yrs","41813064","CDM","983","RC","99382","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 5-11 Yrs","41813072","CDM","983","RC","99383","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 12-17 Yrs","41813080","CDM","983","RC","99384","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 18-39 Yrs","41813098","CDM","983","RC","99385","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 40-64 Yrs","41813106","CDM","983","RC","99386","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt Over 65 Yrs","41813114","CDM","983","RC","99387","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt Under 1 Yr","41813122","CDM","983","RC","99391","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 1-4 Yrs","41813130","CDM","983","RC","99392","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 5-11 Yrs","41813148","CDM","983","RC","99393","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 12-17 Yrs","41813155","CDM","983","RC","99394","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 18-39 Yrs","41813163","CDM","983","RC","99395","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 40-64 Yrs","41813171","CDM","983","RC","99396","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 65>","41813189","CDM","983","RC","99397","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/L Xtremity Art 2 Levels","41813197","CDM","983","RC","93922","HCPCS","","","facility","both","","","","222.62","222.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/Lxtr Art Stdy 3+ Lvls","41813205","CDM","983","RC","93923","HCPCS","","","facility","both","","","","345.5","345.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Report","41813221","CDM","983","RC","","","","","facility","both","","","","23.26","23.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41813248","CDM","983","RC","90471","HCPCS","","","facility","both","","","","34.81","34.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41813255","CDM","983","RC","90472","HCPCS","","","facility","both","","","","31.31","31.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drivers Physical","41813270","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Employment Physical","41813288","CDM","983","RC","99214","HCPCS","","","facility","both","","","","261.06","261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sports/School Physical","41813296","CDM","983","RC","99499","HCPCS","","","facility","both","","","","36.05","36.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg-Technical Fee","41813338","CDM","730","RC","93005","HCPCS","","","facility","both","","","","25","25","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Int Rep","41813346","CDM","983","RC","93010","HCPCS","","","facility","both","","","","19.53","19.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Tray Urimeter","41813361","CDM","272","RC","","","","","facility","both","","","","240.83","240.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/ Micro","41813437","CDM","300","RC","81000","HCPCS","","","facility","both","","","","9","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/O Micro","41813445","CDM","300","RC","81002","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pregnancy Test","41813452","CDM","300","RC","81025","HCPCS","","","facility","both","","","","20","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Blood","41813460","CDM","300","RC","82270","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Fingerstick","41813478","CDM","300","RC","82962","HCPCS","","","facility","both","","","","6","6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spun Hct","41813486","CDM","300","RC","85013","HCPCS","","","facility","both","","","","16","16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ppd","41813494","CDM","300","RC","86580","HCPCS","","","facility","both","","","","22","22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wet Mount","41813502","CDM","300","RC","87210","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Strep Screen","41813510","CDM","300","RC","87880","HCPCS","","","facility","both","","","QW","31","31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Spirometry","41813528","CDM","460","RC","94010","HCPCS","","","facility","both","","","","82","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry Pre And Post","41813536","CDM","460","RC","94060","HCPCS","","","facility","both","","","","138","138","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comfor Knee Immobilizer Univ24","41813569","CDM","271","RC","","","","","facility","both","","","","59.65","59.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Humrl Shft Fx Wo Mnp","41813585","CDM","983","RC","24500","HCPCS","","","facility","both","","","","887.7","887.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk >4.0Cm","41813601","CDM","983","RC","11606","HCPCS","","","facility","both","","","","1094","1094","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate/Inj Ganglion Cyst","41813627","CDM","983","RC","20612","HCPCS","","","facility","both","","","","151.22","151.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Elbow Dislc W/O Anes","41813635","CDM","983","RC","24600","HCPCS","","","facility","both","","","","895.87","895.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 12.6-20Cm","41813668","CDM","983","RC","12005","HCPCS","","","facility","both","","","","411.16","411.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb External Ear","41813692","CDM","983","RC","69200","HCPCS","","","facility","both","","","","201.41","201.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Paste/Unna Boot","41813726","CDM","983","RC","29580","HCPCS","","","facility","both","","","","158.11","158.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Intralesional >7","41813742","CDM","983","RC","11901","HCPCS","","","facility","both","","","","169.64","169.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patella Stabilizer Hinged","41813750","CDM","271","RC","","","","","facility","both","","","","72.14","72.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41813768","CDM","942","RC","G0108","HCPCS","","","facility","both","","","","146","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Nutrician Therapy Ea 15Mi","41813784","CDM","942","RC","97802","HCPCS","","","facility","both","","","","82","82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt, Group, Each 30 Minutes","41813800","CDM","942","RC","97804","HCPCS","","","facility","both","","","","37","37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath","41813818","CDM","983","RC","51702","HCPCS","","","facility","both","","","","154.38","154.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem Add 20 Cm/<","41813834","CDM","983","RC","97598","HCPCS","","","facility","both","","","","113.32","113.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obtaining Screen Pap","41813884","CDM","983","RC","Q0091","HCPCS","","","facility","both","","","","107.68","107.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ca Scn Pelvic/Breast Exam","41813900","CDM","983","RC","G0101","HCPCS","","","facility","both","","","","95.77","95.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Ca Screening Dre","41813918","CDM","983","RC","G0102","HCPCS","","","facility","both","","","","57.72","57.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Preventive Exam","41813934","CDM","983","RC","G0402","HCPCS","","","facility","both","","","","398.34","398.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41813950","CDM","983","RC","G0403","HCPCS","","","facility","both","","","","41.86","41.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41813968","CDM","983","RC","G0405","HCPCS","","","facility","both","","","","19.53","19.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","41813984","CDM","983","RC","99407","HCPCS","","","facility","both","","","","67.14","67.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","41814000","CDM","983","RC","99406","HCPCS","","","facility","both","","","","35.95","35.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Done W/ Colposcopy Addon","41814026","CDM","983","RC","58110","HCPCS","","","facility","both","","","","119.69","119.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Latex Free Volley Tennis Elbow","41814042","CDM","270","RC","","","","","facility","both","","","","64.38","64.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patella Stabilizer W/ Condylar","41814076","CDM","271","RC","L1820","HCPCS","","","facility","both","","","","115.72","115.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc Rem Fb Sq Comp","41814092","CDM","983","RC","10121","HCPCS","","","facility","both","","","","671.68","671.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Nursemaid Elbow","41814142","CDM","983","RC","24640","HCPCS","","","facility","both","","","","250.1","250.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iud Paragard","41814150","CDM","250","RC","J7300","HCPCS","","","facility","both","","","","1009.4","1009.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Svc Req For Power Mobility","41814176","CDM","983","RC","G0372","HCPCS","","","facility","both","","","","21.44","21.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 3.1-4C","41814250","CDM","983","RC","11604","HCPCS","","","facility","both","","","","776.33","776.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rpr Lac Cplx Forehd 1-2.5Cm","41814284","CDM","983","RC","13131","HCPCS","","","facility","both","","","","974.07","974.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Appl Cast Leg Short Walk","41814300","CDM","983","RC","29425","HCPCS","","","facility","both","","","","187.56","187.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Initial Visit","41814318","CDM","983","RC","G0438","HCPCS","","","facility","both","","","","409.8","409.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Subseq Visit","41814326","CDM","983","RC","G0439","HCPCS","","","facility","both","","","","280.37","280.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","41814342","CDM","983","RC","97597","HCPCS","","","facility","both","","","","245.41","245.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Face-Mm B9+Marg 3.1-4 C","41814368","CDM","983","RC","11444","HCPCS","","","facility","both","","","","692.88","692.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Into Skin Lesions =<7","41814385","CDM","983","RC","11900","HCPCS","","","facility","both","","","","137.44","137.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Audiometry Bekesy Screen","41814386","CDM","983","RC","92700","HCPCS","","","facility","both","","","","21.93","21.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","41814387","CDM","983","RC","11042","HCPCS","","","facility","both","","","","317.16","317.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Flap Trunk","41814388","CDM","983","RC","15734","HCPCS","","","facility","both","","","","3508.47","3508.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressng Chg Not For Burn","41814389","CDM","983","RC","15852","HCPCS","","","facility","both","","","","106.17","106.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vacc","41814391","CDM","983","RC","G0009","HCPCS","","","facility","both","","","","175.68","175.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Counseling 15 Min","41814392","CDM","983","RC","99401","HCPCS","","","facility","both","","","","39.28","39.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behavior Counsel Obesity 15M","41814396","CDM","983","RC","G0447","HCPCS","","","facility","both","","","","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Hep A-Havrix","41814397","CDM","999","RC","90633","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Act Hib","41814398","CDM","999","RC","90648","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Hpv-Gardasil9 Or Cervarix","41814399","CDM","999","RC","90651","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Rotavirus-Rotarix Or Rota","41814400","CDM","999","RC","90681","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Pneumococcal Conjugate-Pr","41814401","CDM","999","RC","90670","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Ipv-Kinrix","41814402","CDM","999","RC","90696","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Hib/Polio-Pentacil","41814403","CDM","999","RC","90698","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap-Infanrix","41814404","CDM","999","RC","90700","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Mmr-Mmrii","41814405","CDM","999","RC","90707","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Mmr-V-Proquad","41814406","CDM","999","RC","90710","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Ipv Ipol","41814407","CDM","999","RC","90713","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Tdap/Boostrix Or Adacel","41814408","CDM","999","RC","90715","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Varicella-Varivax","41814409","CDM","999","RC","90716","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Dtap/Hep B/Polio-Pediarix","41814410","CDM","999","RC","90723","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Meningococcal Conjugate-M","41814411","CDM","999","RC","90734","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Hep B-Energix B","41814412","CDM","999","RC","90744","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"Poct Hcg Quan","41814415","CDM","301","RC","84703","HCPCS","","","facility","both","","","QW","14","14","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Repair Entropion Suture","41814416","CDM","983","RC","67921","HCPCS","","","facility","both","","","","1204.46","1204.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ftf Counsel-Alcohol Misuse 15","41814418","CDM","983","RC","G0443","HCPCS","","","facility","both","","","","61.51","61.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"(Frenotomy)Incsn Lingl Frenum","41814419","CDM","983","RC","41010","HCPCS","","","facility","both","","","","542.83","542.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"(Frenotomy)Incsn Labial Frenum","41814420","CDM","983","RC","40806","HCPCS","","","facility","both","","","","263.06","263.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41814421","CDM","983","RC","99221","HCPCS","","","facility","both","","","","232.29","232.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41814422","CDM","983","RC","99222","HCPCS","","","facility","both","","","","315.63","315.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41814423","CDM","983","RC","99223","HCPCS","","","facility","both","","","","465.37","465.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41814424","CDM","983","RC","99231","HCPCS","","","facility","both","","","","89.98","89.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41814425","CDM","983","RC","99232","HCPCS","","","facility","both","","","","166.67","166.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41814426","CDM","983","RC","99233","HCPCS","","","facility","both","","","","240.24","240.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41814427","CDM","983","RC","99238","HCPCS","","","facility","both","","","","170.38","170.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41814428","CDM","983","RC","99239","HCPCS","","","facility","both","","","","250.1","250.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Facility Care Lvl I","41814429","CDM","983","RC","99304","HCPCS","","","facility","both","","","","210.08","210.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Lvl Ii","41814430","CDM","983","RC","99305","HCPCS","","","facility","both","","","","302.28","302.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl I","41814431","CDM","983","RC","99307","HCPCS","","","facility","both","","","","102.98","102.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl Ii","41814432","CDM","983","RC","99308","HCPCS","","","facility","both","","","","162.43","162.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snf D C Day 30 Min","41814433","CDM","983","RC","99315","HCPCS","","","facility","both","","","","171.33","171.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pres/Absn Urine Incon Assess","41814435","CDM","983","RC","1090F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Pls Gn W Mlt Lds","41814436","CDM","983","RC","33231","HCPCS","","","facility","both","","","","874.68","874.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc 3 Cm","41814437","CDM","983","RC","21931","HCPCS","","","facility","both","","","","1056.33","1056.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Dystrophic Nail Any Numbr","41814438","CDM","983","RC","G0127","HCPCS","","","facility","both","","","","58.73","58.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pos Clin Depres Scrn F/U Doc","41814439","CDM","983","RC","G8431","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alcohol/Sub Misuse Assess","41814440","CDM","983","RC","G2011","HCPCS","","","facility","both","","","","37.24","37.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scr Dep Neg, No Plan Reqd","41814441","CDM","983","RC","G8510","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Vfc Pneumococcal 20 Val","41814443","CDM","999","RC","90677","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Beyfortus 50Mg/0.5Ml","41814444","CDM","999","RC","90380","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Beyfortus 100Mg/1Ml","41814445","CDM","999","RC","90381","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Covid Mod 12Y+ 0.5Ml(2023","41814446","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Vfc Covid Mod 6M-11Y 0.25Ml(2","41814447","CDM","999","RC","91322","HCPCS","","","facility","both","","","SL","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier SL: State supplied vaccine"
"*Admn Sarscov2 Vacc 1 Dose","41814450","CDM","983","RC","90480","HCPCS","","","facility","both","","","","63.82","63.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41814451","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reagent Strip/Blood Glucose","41814452","CDM","983","RC","82948","HCPCS","","","facility","both","","","","16.5","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bilirubin Total Transcut","41814453","CDM","983","RC","88720","HCPCS","","","facility","both","","","","10.38","10.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 30","41814454","CDM","983","RC","99402","HCPCS","","","facility","both","","","","121.7","121.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 45","41814455","CDM","983","RC","99403","HCPCS","","","facility","both","","","","181.72","181.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 60","41814456","CDM","983","RC","99404","HCPCS","","","facility","both","","","","240.62","240.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Assmt/Reassessment","41814457","CDM","942","RC","96156","HCPCS","","","facility","both","","","","218.2","218.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Indiv 1St 30","41814458","CDM","942","RC","96158","HCPCS","","","facility","both","","","","147.56","147.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hlth Bhv Ivntj Indiv Ea Addl","41814459","CDM","942","RC","96159","HCPCS","","","facility","both","","","","50.02","50.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","41820004","CDM","983","RC","62270","HCPCS","","","facility","both","","","","436.93","436.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Punc Therapeutic","41820005","CDM","983","RC","62272","HCPCS","","","facility","both","","","","566.91","566.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Into Skin Lesions =<7","41820020","CDM","983","RC","11900","HCPCS","","","facility","both","","","","171.8","171.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Intralesional >7 Les","41820022","CDM","983","RC","11901","HCPCS","","","facility","both","","","","212.06","212.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Tunneled Cvad W Port/Pump","41820024","CDM","983","RC","36590","HCPCS","","","facility","both","","","","660.38","660.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostatic Microware Thermotx","41820026","CDM","983","RC","53850","HCPCS","","","facility","both","","","","5133.83","5133.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx <=50Sqcm","41820030","CDM","983","RC","97605","HCPCS","","","facility","both","","","","135.24","135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Suction Lipectomy Trunk","41820034","CDM","983","RC","15877","HCPCS","","","facility","both","","","","2169.3","2169.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41820038","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sc <2 Cm","41820040","CDM","983","RC","21011","HCPCS","","","facility","both","","","","1136.14","1136.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx/Exc Lymph Node Opn Superfcl","41820046","CDM","983","RC","38500","HCPCS","","","facility","both","","","","1014.04","1014.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry","41820048","CDM","983","RC","94010","HCPCS","","","facility","both","","","","114.36","114.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wedge Resect Of Lung Initial","41820050","CDM","983","RC","32505","HCPCS","","","facility","both","","","","2623.44","2623.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Corpora Cavernosa W/Pharm","41820053","CDM","983","RC","54235","HCPCS","","","facility","both","","","","267.95","267.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pge 1 Trimix 0.1 Ml","41820055","CDM","636","RC","J3490","HCPCS","","","facility","both","","","","4.02","4.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cavernosometry W/Med Inj","41820057","CDM","983","RC","54231","HCPCS","","","facility","both","","","","426.18","426.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Perianal Abscess","41820059","CDM","983","RC","46050","HCPCS","","","facility","both","","","","704.31","704.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ben Les Trunk 3.1-4.0 Cm","41820061","CDM","983","RC","11404","HCPCS","","","facility","both","","","","687.5","687.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cysto W Dil Or Ureth Strict","41820063","CDM","983","RC","52281","HCPCS","","","facility","both","","","","1013.09","1013.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Trigger Points 3/>","41820071","CDM","983","RC","20553","HCPCS","","","facility","both","","","","195.19","195.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Of Breast Tissue","41820073","CDM","983","RC","19300","HCPCS","","","facility","both","","","","1693.11","1693.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eval Mastectomy Flap Perf-Unil","41820075","CDM","983","RC","19499","HCPCS","","","facility","both","","","","145.23","145.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eval Mastectomy Flap Perf-Bila","41820076","CDM","983","RC","19499","HCPCS","","","facility","both","","","50","172.01","172.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure"
"Bx Breast 1St Lesion Strtctc","41820103","CDM","983","RC","19081","HCPCS","","","facility","both","","","","1978.03","1978.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast Add Lesion Strctc","41820104","CDM","983","RC","19082","HCPCS","","","facility","both","","","","1622.48","1622.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast 1St Lesion Us Imag","41820105","CDM","983","RC","19083","HCPCS","","","facility","both","","","","1960.45","1960.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast Add Lesion Us Imag","41820106","CDM","983","RC","19084","HCPCS","","","facility","both","","","","1581.39","1581.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast 1St Lesion Mr Imag","41820107","CDM","983","RC","19085","HCPCS","","","facility","both","","","","3027.1","3027.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Breast Add Lesion Mr Imag","41820108","CDM","983","RC","19086","HCPCS","","","facility","both","","","","2436.14","2436.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Dynamic Cavernosemetry W/Me","41820110","CDM","983","RC","54231","HCPCS","","","facility","both","","","","426.18","426.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41820111","CDM","983","RC","99091","HCPCS","","","facility","both","","","","167.3","167.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Pos Airway Pressure Cpap","41820113","CDM","983","RC","94660","HCPCS","","","facility","both","","","","195.99","195.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision Other Than Clamp","41820114","CDM","983","RC","54160","HCPCS","","","facility","both","","","","678.1","678.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hip/Pelvis Les Sc < 3 Cm","41820115","CDM","983","RC","27047","HCPCS","","","facility","both","","","","1480.76","1480.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Tunneled Cv Cath","41820119","CDM","983","RC","36589","HCPCS","","","facility","both","","","","497.73","497.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl Tissue Marker 3 Pack","41820121","CDM","278","RC","A4648","HCPCS","","","facility","both","","","","659.84","659.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Rt Device/Marker Pros","41820123","CDM","983","RC","55876","HCPCS","","","facility","both","","","","447.69","447.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Non-Tunnel Cv Cath 5 Yrs/>","41820141","CDM","983","RC","36556","HCPCS","","","facility","both","","","","673.41","673.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Picc Age 5 Yrs/>","41820142","CDM","983","RC","36569","HCPCS","","","facility","both","","","","273.6","273.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Muscle Deep","41820143","CDM","983","RC","20525","HCPCS","","","facility","both","","","","1504.54","1504.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pelviv Lymphadenectomy","41820144","CDM","983","RC","38770","HCPCS","","","facility","both","","","","2339.16","2339.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W U W Ureteral Stricture","41820145","CDM","983","RC","52344","HCPCS","","","facility","both","","","","1065.9","1065.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Radical Prostatectomy","41820146","CDM","983","RC","55866","HCPCS","","","facility","both","","","","4198.33","4198.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Urethral Divertic Female","41820147","CDM","983","RC","53230","HCPCS","","","facility","both","","","","1789.68","1789.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Stone Manip Or Rem","41820148","CDM","983","RC","52352","HCPCS","","","facility","both","","","","1024.31","1024.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Kidney Open","41820149","CDM","983","RC","50220","HCPCS","","","facility","both","","","","3039.74","3039.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Multi Obstr Clot Rem","41820150","CDM","983","RC","52001","HCPCS","","","facility","both","","","","1261.7","1261.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystolithotomy W Rem Stone Wo","41820151","CDM","983","RC","51050","HCPCS","","","facility","both","","","","1392.59","1392.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hidrad Umbil S I Rep","41820152","CDM","983","RC","11470","HCPCS","","","facility","both","","","","1346.81","1346.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Lesion Removal","41820153","CDM","983","RC","45384","HCPCS","","","facility","both","","","","1489.79","1489.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Laser Enucleation","41820154","CDM","983","RC","52649","HCPCS","","","facility","both","","","","2421.66","2421.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Resection","41820155","CDM","983","RC","45390","HCPCS","","","facility","both","","","","974.26","974.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto/Uretero W/Lithotripsy","41820156","CDM","983","RC","52356","HCPCS","","","facility","both","","","","1199.44","1199.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reopen Recent Laparotomy","41820157","CDM","983","RC","49002","HCPCS","","","facility","both","","","","2976.39","2976.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemorrhoidopexy By Stapling","41820158","CDM","983","RC","46947","HCPCS","","","facility","both","","","","1130.89","1130.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Neck Tum Deep < 5 Cm","41820159","CDM","983","RC","21556","HCPCS","","","facility","both","","","","1554.61","1554.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tunneled Cvad W Port Age 5","41820163","CDM","983","RC","36561","HCPCS","","","facility","both","","","","3465.23","3465.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroguide For Vein Device","41820164","CDM","983","RC","77001","HCPCS","","","facility","both","","","26","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Colectomy P W Coloproctostomy","41820165","CDM","983","RC","44145","HCPCS","","","facility","both","","","","4713.18","4713.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Take-Down Splen Flexure W P Co","41820166","CDM","983","RC","44139","HCPCS","","","facility","both","","","","338.97","338.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colectomy Partial W Anastomos","41820167","CDM","983","RC","44140","HCPCS","","","facility","both","","","","3823.51","3823.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Sm Intest Sgl Resect","41820168","CDM","983","RC","44120","HCPCS","","","facility","both","","","","3472.85","3472.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Local Ulcer B Tumor","41820169","CDM","983","RC","43610","HCPCS","","","facility","both","","","","2795.57","2795.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Abdom Abscess Open","41820170","CDM","983","RC","49020","HCPCS","","","facility","both","","","","4547.19","4547.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Ruptured Spleen W/Wo Parti","41820171","CDM","983","RC","38115","HCPCS","","","facility","both","","","","3626.53","3626.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit I","41820172","CDM","983","RC","99281","HCPCS","","","facility","both","","","","62.85","62.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Ii","41820173","CDM","983","RC","99282","HCPCS","","","facility","both","","","","121.11","121.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iii","41820174","CDM","983","RC","99283","HCPCS","","","facility","both","","","","180.92","180.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","41820175","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Manip Wo Rem Of Calcul","41820176","CDM","983","RC","52330","HCPCS","","","facility","both","","","","1833.35","1833.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pyeloplasty Complicated","41820177","CDM","983","RC","50405","HCPCS","","","facility","both","","","","4062.51","4062.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tur Postop Bladder Neck Contr","41820178","CDM","983","RC","52640","HCPCS","","","facility","both","","","","950.38","950.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","41820179","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Appl Cast Leg Short Walk","41820180","CDM","983","RC","29425","HCPCS","","","facility","both","","","","234.46","234.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Dstl Fib Fx Wo Mnp","41820181","CDM","983","RC","27786","HCPCS","","","facility","both","","","","973.43","973.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","41820182","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","41820183","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41820184","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Diaphr Hernia Not Nn Acut","41820185","CDM","983","RC","39540","HCPCS","","","facility","both","","","","2475.55","2475.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tmj Arthrotomy - 21010","41820187","CDM","983","RC","21010","HCPCS","","","facility","both","","","","2263.12","2263.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exploration Of Chest - 32100","41820188","CDM","983","RC","32100","HCPCS","","","facility","both","","","","2280.94","2280.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 12.6-20Cm","41820189","CDM","983","RC","12005","HCPCS","","","facility","both","","","","513.95","513.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Srep F/E/N/L/Mm 12.6-20.0 Cm","41820190","CDM","983","RC","12016","HCPCS","","","facility","both","","","","641.82","641.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair N-Hf/Genit","41820191","CDM","983","RC","12046","HCPCS","","","facility","both","","","","1511.73","1511.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sling For Stress Incontinence","41820192","CDM","983","RC","57288","HCPCS","","","facility","both","","","","2155.6","2155.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Colostomy","41820193","CDM","983","RC","44188","HCPCS","","","facility","both","","","","3535.58","3535.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W Bil Tot Pelvic Lymphadec","41820194","CDM","983","RC","38571","HCPCS","","","facility","both","","","","1934.22","1934.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Sm Intest Ea Add Resec","41820195","CDM","983","RC","44121","HCPCS","","","facility","both","","","","675.42","675.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bld Flow Test","41820196","CDM","983","RC","15860","HCPCS","","","facility","both","","","","307.76","307.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Device Breast 1St Imag","41820197","CDM","983","RC","19281","HCPCS","","","facility","both","","","","778.94","778.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ra Tracer Id Of Sentinl Node","41820198","CDM","983","RC","38792","HCPCS","","","facility","both","","","","262.86","262.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracoscopy Contrl Bleeding -","41820199","CDM","983","RC","32654","HCPCS","","","facility","both","","","","3280.7","3280.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Shave Les Scalp 0.6-1C","41820200","CDM","983","RC","11306","HCPCS","","","facility","both","","","","391.33","391.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Mark Abd/Pel For Rt Perq -","41820201","CDM","983","RC","49411","HCPCS","","","facility","both","","","","1565.73","1565.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Inj Corpora Cavernosa W/Pha","41820202","CDM","983","RC","54235","HCPCS","","","facility","both","","","","267.95","267.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Njx Px Nfrosgrm Urtrgrm 50","41820203","CDM","983","RC","50431","HCPCS","","","facility","both","","","","849.03","849.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Desctruc Lesn Penis Smp Exc","41820204","CDM","983","RC","54060","HCPCS","","","facility","both","","","","582.55","582.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guide Vascular Access","41820205","CDM","983","RC","76937","HCPCS","","","facility","both","","","","115.28","115.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mg Liver Hemorr Ext Debrd Coag","41820206","CDM","983","RC","47361","HCPCS","","","facility","both","","","","8570.22","8570.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephrectomy Radical","41820208","CDM","983","RC","50230","HCPCS","","","facility","both","","","","3714.98","3714.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Nl/Pl Lithotrp Ext Up 2Cm","41820209","CDM","983","RC","50080","HCPCS","","","facility","both","","","","2539","2539","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc Rem Fb Sq Comp","41820210","CDM","983","RC","10121","HCPCS","","","facility","both","","","","839.6","839.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Deb Musc/Fascia 20 Sq Cm/<","41820211","CDM","983","RC","11043","HCPCS","","","facility","both","","","","706.07","706.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","41820212","CDM","983","RC","11044","HCPCS","","","facility","both","","","","938.02","938.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue Add-On =<20 Sq","41820213","CDM","983","RC","11045","HCPCS","","","facility","both","","","","125.11","125.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Hidrad Axil S I Rep","41820214","CDM","983","RC","11450","HCPCS","","","facility","both","","","","1274.93","1274.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Hidrad Axil Cplx Rep","41820215","CDM","983","RC","11451","HCPCS","","","facility","both","","","","1577.11","1577.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Hidrad Ing S I Rep","41820216","CDM","983","RC","11462","HCPCS","","","facility","both","","","","1247.59","1247.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Pilonid Cyst Extens","41820217","CDM","983","RC","11771","HCPCS","","","facility","both","","","","1838.09","1838.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Repl Te W Perm Prosth","41820219","CDM","983","RC","11970","HCPCS","","","facility","both","","","","1833.79","1833.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep S A L 2.6-7.5Cm","41820220","CDM","983","RC","13121","HCPCS","","","facility","both","","","","1346.9","1346.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Acellular Derm Matrix Implt","41820221","CDM","983","RC","15777","HCPCS","","","facility","both","","","","623.87","623.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Breast Les By N Loc Sg","41820222","CDM","983","RC","19125","HCPCS","","","facility","both","","","","1659.43","1659.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Partial Mastectomy","41820223","CDM","983","RC","19301","HCPCS","","","facility","both","","","","1888.47","1888.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf P-Mastectomy W/Ln Removal","41820224","CDM","983","RC","19302","HCPCS","","","facility","both","","","","2592.13","2592.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Mast Simple Complete","41820225","CDM","983","RC","19303","HCPCS","","","facility","both","","","","2750.92","2750.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduction Mammaplasty","41820227","CDM","983","RC","19318","HCPCS","","","facility","both","","","","3245.2","3245.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Breast Reconst W Tiss Exp","41820228","CDM","983","RC","19357","HCPCS","","","facility","both","","","","4555.93","4555.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Breast Reconstr W/Lat Flap","41820229","CDM","983","RC","19361","HCPCS","","","facility","both","","","","4639.53","4639.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Breast Capsulotomy","41820230","CDM","983","RC","19370","HCPCS","","","facility","both","","","","2067.83","2067.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Periprosth Capsulect Breast","41820231","CDM","983","RC","19371","HCPCS","","","facility","both","","","","2359.03","2359.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Revise Reconstr Breast","41820232","CDM","983","RC","19380","HCPCS","","","facility","both","","","","2331.69","2331.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rem Fb Muscle Smpl","41820233","CDM","983","RC","20520","HCPCS","","","facility","both","","","","659.97","659.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sbq 2 Cm/>","41820235","CDM","983","RC","21012","HCPCS","","","facility","both","","","","1004.56","1004.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Tum Deep 2 Cm/>","41820236","CDM","983","RC","21014","HCPCS","","","facility","both","","","","1548.78","1548.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Op Tx Orbit Flr Fx Periorb","41820237","CDM","983","RC","21390","HCPCS","","","facility","both","","","","2407.04","2407.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cl Tx Of Mand Fx W Id Fix","41820238","CDM","983","RC","21453","HCPCS","","","facility","both","","","","3230.01","3230.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Soft Tissue Neck/Thorax","41820239","CDM","983","RC","21550","HCPCS","","","facility","both","","","","831.06","831.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Neck Les Sc 3 Cm/>","41820240","CDM","983","RC","21552","HCPCS","","","facility","both","","","","1299.78","1299.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Neck Tum Deep 5 Cm/>","41820241","CDM","983","RC","21554","HCPCS","","","facility","both","","","","2122.39","2122.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc < 3 Cm","41820243","CDM","983","RC","21930","HCPCS","","","facility","both","","","","1508.02","1508.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Les Sc 3 Cm/>","41820244","CDM","983","RC","21931","HCPCS","","","facility","both","","","","1368.56","1368.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Tum Deep < 5 Cm","41820245","CDM","983","RC","21932","HCPCS","","","facility","both","","","","1927.59","1927.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Back Tum Deep 5 Cm/>","41820246","CDM","983","RC","21933","HCPCS","","","facility","both","","","","2139.7","2139.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Abdl Tum Deep < 5 Cm","41820247","CDM","983","RC","22900","HCPCS","","","facility","both","","","","1637.49","1637.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Abd Les Sc < 3 Cm","41820248","CDM","983","RC","22902","HCPCS","","","facility","both","","","","1407.67","1407.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Shldr Deep Absc","41820249","CDM","983","RC","23030","HCPCS","","","facility","both","","","","1366.84","1366.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Shoulder Les Sc 3 Cm/>","41820250","CDM","983","RC","23071","HCPCS","","","facility","both","","","","1231.47","1231.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Shoulder Tum Deep 5 Cm/>","41820251","CDM","983","RC","23073","HCPCS","","","facility","both","","","","2033.4","2033.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Arm/Elbow Les Sc 3 Cm/>","41820252","CDM","983","RC","24071","HCPCS","","","facility","both","","","","1190.81","1190.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Forearm Tum Deep 3 Cm/>","41820253","CDM","983","RC","25073","HCPCS","","","facility","both","","","","1591.23","1591.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep Fb Rem - Forearm/Wrist","41820254","CDM","983","RC","25248","HCPCS","","","facility","both","","","","1242.15","1242.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Tendon Sheath Incision","41820255","CDM","983","RC","26055","HCPCS","","","facility","both","","","","1758.81","1758.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep I D Thigh Knee","41820256","CDM","983","RC","27301","HCPCS","","","facility","both","","","","2077.85","2077.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Electr Resection-Prostat","41820257","CDM","983","RC","52601","HCPCS","","","facility","both","","","","2131.87","2131.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intubation Et Emergent","41820258","CDM","983","RC","31500","HCPCS","","","facility","both","","","","400.91","400.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/O Imag","41820260","CDM","983","RC","32556","HCPCS","","","facility","both","","","","2201.16","2201.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracoscopy Remove Cortex","41820261","CDM","983","RC","32651","HCPCS","","","facility","both","","","","3074.19","3074.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Tunneled Cv Cath Age 5/>","41820262","CDM","983","RC","36558","HCPCS","","","facility","both","","","","2626.4","2626.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ins Picc Device W Port 5 Yr","41820264","CDM","983","RC","36571","HCPCS","","","facility","both","","","","4244.96","4244.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Repl Tunneled Vad W Port","41820265","CDM","983","RC","36582","HCPCS","","","facility","both","","","","3208.12","3208.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arterial Cath - Mntr/Transfuse","41820266","CDM","983","RC","36620","HCPCS","","","facility","both","","","","125.63","125.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Bx Exc Ln Deep Cerv Nodes","41820268","CDM","983","RC","38510","HCPCS","","","facility","both","","","","1571.63","1571.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Open Bx Exc Ln Axillary No","41820269","CDM","983","RC","38525","HCPCS","","","facility","both","","","","1271.69","1271.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Axillary Lymphadenectomy C","41820270","CDM","983","RC","38745","HCPCS","","","facility","both","","","","2522.93","2522.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Io Map Of Sent Lymph Node","41820271","CDM","983","RC","38900","HCPCS","","","facility","both","","","","385.46","385.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Myotomy Heller","41820272","CDM","983","RC","43279","HCPCS","","","facility","both","","","","3644.79","3644.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Esophagogastric Fundoplsty","41820273","CDM","983","RC","43280","HCPCS","","","facility","both","","","","3069.45","3069.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Esoph Fundoplasty Thor","41820274","CDM","983","RC","43328","HCPCS","","","facility","both","","","","3148.38","3148.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colectomy P W Coloproctost","41820278","CDM","983","RC","44146","HCPCS","","","facility","both","","","","6054.55","6054.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf P Colectomy W Rem Ilium","41820279","CDM","983","RC","44160","HCPCS","","","facility","both","","","","3543.35","3543.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Partial Colectomy","41820280","CDM","983","RC","44204","HCPCS","","","facility","both","","","","4385.23","4385.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap P Colectomy  W Rem Ileu","41820281","CDM","983","RC","44205","HCPCS","","","facility","both","","","","3818.02","3818.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf L Colectomy/Coloproctostomy","41820282","CDM","983","RC","44207","HCPCS","","","facility","both","","","","5179.61","5179.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Close Enterostomy","41820284","CDM","983","RC","44227","HCPCS","","","facility","both","","","","4736.71","4736.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ileostomy/Jejunostomy","41820285","CDM","983","RC","44310","HCPCS","","","facility","both","","","","2982.29","2982.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Close Enterostomy W Resect","41820286","CDM","983","RC","44625","HCPCS","","","facility","both","","","","2906.51","2906.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Close Enterostomy W Resect","41820287","CDM","983","RC","44626","HCPCS","","","facility","both","","","","4535.68","4535.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Laparoscopy Appendectomy","41820288","CDM","983","RC","44970","HCPCS","","","facility","both","","","","1729.8","1729.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Proctectomy Cplt Abdominop","41820289","CDM","983","RC","45110","HCPCS","","","facility","both","","","","5298.63","5298.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf I D Perirectal Or Ischial","41820290","CDM","983","RC","46040","HCPCS","","","facility","both","","","","1683.67","1683.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Of Anal Tags","41820292","CDM","983","RC","46230","HCPCS","","","facility","both","","","","918.33","918.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Remove Int/Ext Hem 1 Group","41820293","CDM","983","RC","46255","HCPCS","","","facility","both","","","","1605.39","1605.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Remove In/Ex Hem Groups 2+","41820294","CDM","983","RC","46260","HCPCS","","","facility","both","","","","1422.86","1422.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Remove Anal Fist Inter","41820295","CDM","983","RC","46275","HCPCS","","","facility","both","","","","1714.83","1714.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Of Hemorrhoid Clot","41820296","CDM","983","RC","46320","HCPCS","","","facility","both","","","","619.94","619.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Needle Bx Liver At Major O","41820297","CDM","983","RC","47001","HCPCS","","","facility","both","","","","289.95","289.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Bx Of Liver Wedge","41820298","CDM","983","RC","47100","HCPCS","","","facility","both","","","","2453.15","2453.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laser Vaporization Of Prostate","41820299","CDM","983","RC","52648","HCPCS","","","facility","both","","","","5354.66","5354.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Cholecystecomy","41820300","CDM","983","RC","47562","HCPCS","","","facility","both","","","","1891.13","1891.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Cholecystectomy W Chol","41820301","CDM","983","RC","47563","HCPCS","","","facility","both","","","","2055.83","2055.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Dx Abdomen Peritoneum","41820302","CDM","983","RC","49320","HCPCS","","","facility","both","","","","949.06","949.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Prp I/Hern Init Reduc 5+ Yr","41820303","CDM","983","RC","49505","HCPCS","","","facility","both","","","","1507.82","1507.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Prp I/Hern Init Block 5+ Yr","41820304","CDM","983","RC","49507","HCPCS","","","facility","both","","","","1690.75","1690.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Repair Recurrent Inguinal H","41820305","CDM","983","RC","49520","HCPCS","","","facility","both","","","","1816.3","1816.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Ing Hernia Repair Init","41820313","CDM","983","RC","49650","HCPCS","","","facility","both","","","","1250.01","1250.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Ing Hernia Repair Recur","41820314","CDM","983","RC","49651","HCPCS","","","facility","both","","","","1625.03","1625.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eswl","41820321","CDM","983","RC","50590","HCPCS","","","facility","both","","","","2242.77","2242.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf 2' Suture Abd Wall For Evis","41820322","CDM","983","RC","49900","HCPCS","","","facility","both","","","","2371.94","2371.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Lesion Spermatic Cord","41820323","CDM","983","RC","55520","HCPCS","","","facility","both","","","","1327.38","1327.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Thyroidectomy Total Or Comp","41820324","CDM","983","RC","60240","HCPCS","","","facility","both","","","","2643.24","2643.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Otoplasty Protruding Ear Wi","41820326","CDM","983","RC","69300","HCPCS","","","facility","both","","","","1909.31","1909.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orchiectom Radical - Ing Appr","41820327","CDM","983","RC","54530","HCPCS","","","facility","both","","","","1498.83","1498.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroscope Exam =< 1 Hr","41820328","CDM","983","RC","76000","HCPCS","","","facility","both","","","","131.72","131.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Surgical Specimen Xr","41820329","CDM","983","RC","76098","HCPCS","","","facility","both","","","","135.84","135.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41820331","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41820332","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41820335","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observ/Hosp Same Date Lvl I","41820336","CDM","983","RC","99234","HCPCS","","","facility","both","","","","381.98","381.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41820337","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iliac Revasc W/Stent","41820338","CDM","983","RC","37221","HCPCS","","","facility","both","","","","12911.36","12911.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orchiopexy Inguinal Approach","41820339","CDM","983","RC","54640","HCPCS","","","facility","both","","","","1268.55","1268.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Litholapxy Blad Rem Frag 2.5","41820340","CDM","983","RC","52318","HCPCS","","","facility","both","","","","1364.7","1364.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","41820342","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Varicocel/Lig Sperm Vein","41820343","CDM","983","RC","55535","HCPCS","","","facility","both","","","","1273.21","1273.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Lithotripsy","41820344","CDM","983","RC","52353","HCPCS","","","facility","both","","","","1132.66","1132.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Ing Hernia Init Reduce 0.5","41820345","CDM","983","RC","49500","HCPCS","","","facility","both","","","","1206.42","1206.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Hydrocele Unilateral","41820346","CDM","983","RC","55040","HCPCS","","","facility","both","","","","1001.11","1001.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg > 4 Cm","41820347","CDM","983","RC","11446","HCPCS","","","facility","both","","","","1180.86","1180.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Spermatocele Epididimectm","41820348","CDM","983","RC","54840","HCPCS","","","facility","both","","","","954.04","954.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Fragm Of Calculus","41820349","CDM","983","RC","52325","HCPCS","","","facility","both","","","","924.17","924.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Excise Anal Ext Tag/Papilla","41820350","CDM","983","RC","46220","HCPCS","","","facility","both","","","","726.75","726.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Mobil Splenic Fl Add-On","41820351","CDM","983","RC","44213","HCPCS","","","facility","both","","","","526.9","526.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Neuroplasty Median Nerve A","41820353","CDM","983","RC","64721","HCPCS","","","facility","both","","","","1323.76","1323.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Pilonid Cyt Compl","41820356","CDM","983","RC","11772","HCPCS","","","facility","both","","","","2230.6","2230.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Neck Les Sc < 3 Cm","41820357","CDM","983","RC","21555","HCPCS","","","facility","both","","","","1324.73","1324.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Of Support Implant","41820359","CDM","983","RC","20670","HCPCS","","","facility","both","","","","1199.13","1199.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Splenectomy Total","41820360","CDM","983","RC","38100","HCPCS","","","facility","both","","","","3273.13","3273.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Mast Mod Rad","41820361","CDM","983","RC","19307","HCPCS","","","facility","both","","","","3478.5","3478.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Chest Tube","41820362","CDM","983","RC","32551","HCPCS","","","facility","both","","","","442.83","442.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","41820363","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41820364","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Fulg Bladdr Tumo 2.0-5.0","41820367","CDM","983","RC","52235","HCPCS","","","facility","both","","","","834.56","834.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Removal Of Calculus","41820368","CDM","983","RC","52320","HCPCS","","","facility","both","","","","712.61","712.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Bladdr Tumor 0.5-2.0Cm","41820369","CDM","983","RC","52234","HCPCS","","","facility","both","","","","711.19","711.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Fulgeration Of Trigone","41820370","CDM","983","RC","52214","HCPCS","","","facility","both","","","","2381.13","2381.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cyst W Inst Indwelling Ureter","41820371","CDM","983","RC","52332","HCPCS","","","facility","both","","","","1463.86","1463.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethroscopy W/Uteral Stn","41820372","CDM","983","RC","52005","HCPCS","","","facility","both","","","","930.3","930.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Bladder Cath Complex","41820373","CDM","983","RC","51703","HCPCS","","","facility","both","","","","431.55","431.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chng Cystost Tube Comp","41820375","CDM","983","RC","51710","HCPCS","","","facility","both","","","","411.16","411.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41820376","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/O Micro","41820377","CDM","300","RC","81002","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Penetrating Wdn Extremity","41820378","CDM","983","RC","20103","HCPCS","","","facility","both","","","","1797.04","1797.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl P Wnd Neck","41820379","CDM","983","RC","20100","HCPCS","","","facility","both","","","","1720.23","1720.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep F G H F 1-2.5Cm","41820380","CDM","983","RC","13131","HCPCS","","","facility","both","","","","1217.59","1217.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Rep Trunk Ea Addtl 5 Cm/<","41820381","CDM","983","RC","13102","HCPCS","","","facility","both","","","","370.61","370.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Anal Fist Subq","41820383","CDM","983","RC","46270","HCPCS","","","facility","both","","","","1626.19","1626.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Bles S N Ex G 3.1-4.0Cm","41820384","CDM","983","RC","11424","HCPCS","","","facility","both","","","","722.6","722.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reposit Cvc W Fluoro","41820385","CDM","983","RC","36597","HCPCS","","","facility","both","","","","418.62","418.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Bx Deep","41820386","CDM","983","RC","20205","HCPCS","","","facility","both","","","","918.27","918.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Les Sc 3 Cm/>","41820387","CDM","983","RC","22903","HCPCS","","","facility","both","","","","1278.59","1278.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ivp W/Wo Tomo/Kub","41820388","CDM","983","RC","74400","HCPCS","","","facility","both","","","","417.3","417.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Penile Prosthesis Non-Inf","41820392","CDM","983","RC","54400","HCPCS","","","facility","both","","","","1566.08","1566.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plethysmography","41820393","CDM","983","RC","94726","HCPCS","","","facility","both","","","","173.37","173.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"C0 Diffuse Capacity","41820394","CDM","983","RC","94729","HCPCS","","","facility","both","","","","184.34","184.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Colostomy W Rep Pc Hern","41820395","CDM","983","RC","44346","HCPCS","","","facility","both","","","","3392.15","3392.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enterolysis","41820396","CDM","983","RC","44005","HCPCS","","","facility","both","","","","3109.21","3109.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Sml Intest Mult Perf","41820397","CDM","983","RC","44603","HCPCS","","","facility","both","","","","4592.53","4592.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Bladder Wound Simple","41820398","CDM","983","RC","51860","HCPCS","","","facility","both","","","","2176.39","2176.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Of Nasal Bone Fx W Stabi","41820399","CDM","983","RC","21320","HCPCS","","","facility","both","","","","804.28","804.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Corpora Cavernosa-Glans Penis","41820400","CDM","983","RC","54435","HCPCS","","","facility","both","","","","1231.88","1231.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Rem Fb/Stnt Ureth Comp","41820401","CDM","983","RC","52315","HCPCS","","","facility","both","","","","1433.91","1433.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry Pre And Post","41820403","CDM","983","RC","94060","HCPCS","","","facility","both","","","","191.53","191.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slit Prepuce Dorsal Or Lat","41820404","CDM","983","RC","54001","HCPCS","","","facility","both","","","","596.47","596.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Renal Endo - Estab N/P Ostomy","41820405","CDM","983","RC","50551","HCPCS","","","facility","both","","","","1075.35","1075.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Lefort I Fx W Id W Fix","41820406","CDM","983","RC","21421","HCPCS","","","facility","both","","","","2126.57","2126.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Lap Procedure Liver","41820410","CDM","983","RC","47379","HCPCS","","","facility","both","","","","2452.43","2452.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/Tr/Ext 30.0","41820412","CDM","983","RC","12037","HCPCS","","","facility","both","","","","1494.12","1494.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystostomy Cystotomy W Drainag","41820413","CDM","983","RC","51040","HCPCS","","","facility","both","","","","864.92","864.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retro Inj Urethra","41820414","CDM","983","RC","51610","HCPCS","","","facility","both","","","","379.66","379.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Renal Endo Est Ostomy W U Cath","41820415","CDM","983","RC","50553","HCPCS","","","facility","both","","","","1149.87","1149.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Convert Nephrostomy Catheter","41820417","CDM","983","RC","50434","HCPCS","","","facility","both","","","","3009.04","3009.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove In/Ex Hem 2+ Grps W/Fis","41820419","CDM","983","RC","46262","HCPCS","","","facility","both","","","","1662.42","1662.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balloon Dilate Urtrl Strix","41820420","CDM","983","RC","50706","HCPCS","","","facility","both","","","","3113.95","3113.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ear Partial Smpl Repair","41820421","CDM","983","RC","69110","HCPCS","","","facility","both","","","","1460.39","1460.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Prostate 1-2 Stages","41820422","CDM","983","RC","55821","HCPCS","","","facility","both","","","","2555.02","2555.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rad Resect Abd Tumor 5 Cm/>","41820423","CDM","983","RC","22905","HCPCS","","","facility","both","","","","3812.26","3812.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","41820426","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Im Ins Breast Prosth S/P M","41820427","CDM","983","RC","19340","HCPCS","","","facility","both","","","","2932.89","2932.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Dil Of Bladder Gen Ane","41820428","CDM","983","RC","52260","HCPCS","","","facility","both","","","","610.07","610.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Mand/Maxill Alveolar Rg","41820429","CDM","983","RC","21440","HCPCS","","","facility","both","","","","2043.16","2043.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Split Grft Trnk/Arm/Leg 100Sq","41820430","CDM","983","RC","15100","HCPCS","","","facility","both","","","","2622.67","2622.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splt Graft Fac/Nck/Hf/G 100Sq","41820431","CDM","983","RC","15120","HCPCS","","","facility","both","","","","2580.2","2580.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wnd Prep 1St 100 Sq Cm/1% Ba","41820433","CDM","983","RC","15004","HCPCS","","","facility","both","","","","1225.58","1225.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wnd Prep Trk/Arm/Leg 100Sq Cm","41820434","CDM","983","RC","15002","HCPCS","","","facility","both","","","","1076.06","1076.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure, Anus","41820435","CDM","983","RC","46999","HCPCS","","","facility","both","","","","954.27","954.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Urethral Susp Stress Inco","41820436","CDM","983","RC","51990","HCPCS","","","facility","both","","","","2184.08","2184.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Ablate Renal Mass","41820437","CDM","983","RC","50542","HCPCS","","","facility","both","","","","3398.69","3398.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Fulg Minor Les <0.5Cm","41820438","CDM","983","RC","52224","HCPCS","","","facility","both","","","","2476.43","2476.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Dir Vis Int Urethrotomy","41820439","CDM","983","RC","52276","HCPCS","","","facility","both","","","","765.11","765.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exchange Nephrostomy Cath","41820441","CDM","983","RC","50435","HCPCS","","","facility","both","","","","1864.33","1864.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemo Hormon Antineopl Sq/Im","41820442","CDM","983","RC","96402","HCPCS","","","facility","both","","","","100.84","100.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Grft T/A/L Add 100Sq Cm/1%","41820443","CDM","983","RC","15101","HCPCS","","","facility","both","","","","583.32","583.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"O Tx Comp Cran Nrv Fx W Int F","41820444","CDM","983","RC","21365","HCPCS","","","facility","both","","","","3258.87","3258.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Irrigate Corpora Cav For Priap","41820445","CDM","983","RC","54220","HCPCS","","","facility","both","","","","648.95","648.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Web Fingr W Flaps Grfts","41820446","CDM","983","RC","26561","HCPCS","","","facility","both","","","","2897.85","2897.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Nl/Pl Lithotrp Cplx>2Cm","41820447","CDM","983","RC","50081","HCPCS","","","facility","both","","","","3722.32","3722.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Nephrostomy Catheter","41820448","CDM","983","RC","50432","HCPCS","","","facility","both","","","","2911.07","2911.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add  =<20Sq Cm","41820449","CDM","983","RC","11046","HCPCS","","","facility","both","","","","217.88","217.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wound Tx >50Cm","41820450","CDM","983","RC","97606","HCPCS","","","facility","both","","","","160.45","160.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethtro W/Implant","41820451","CDM","983","RC","52441","HCPCS","","","facility","both","","","","4501","4501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethtro W/ Add Implant","41820452","CDM","983","RC","52442","HCPCS","","","facility","both","","","","3333.52","3333.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Thigh/Knee Les Sc<3 Cm","41820453","CDM","983","RC","27327","HCPCS","","","facility","both","","","","1520.31","1520.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Thigh/Knee Les Sc 3Cm/>","41820454","CDM","983","RC","27337","HCPCS","","","facility","both","","","","1226.68","1226.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephrectomy Partial","41820456","CDM","983","RC","50240","HCPCS","","","facility","both","","","","3861.4","3861.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Lavage","41820458","CDM","983","RC","31624","HCPCS","","","facility","both","","","","783.55","783.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap - Radical Nephrectomy","41820459","CDM","983","RC","50545","HCPCS","","","facility","both","","","","3884.2","3884.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Biopsy Or Les Fulg","41820461","CDM","983","RC","52354","HCPCS","","","facility","both","","","","1204.67","1204.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Suture Or Staple W/ Anesth","41820462","CDM","983","RC","15851","HCPCS","","","facility","both","","","","325.38","325.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholecystectomy","41820463","CDM","983","RC","47600","HCPCS","","","facility","both","","","","3056.97","3056.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Diaphr Hernia Chronic","41820464","CDM","983","RC","39541","HCPCS","","","facility","both","","","","2668.83","2668.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Nasal Septal Fx","41820466","CDM","983","RC","21337","HCPCS","","","facility","both","","","","1290.51","1290.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep F G H F 2.6-7.5Cm","41820467","CDM","983","RC","13132","HCPCS","","","facility","both","","","","1486.14","1486.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep H A G Extr Ea Add 5 C","41820468","CDM","983","RC","13133","HCPCS","","","facility","both","","","","529.5","529.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Palate Or Maxillary Fx","41820469","CDM","983","RC","21422","HCPCS","","","facility","both","","","","1939.52","1939.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Att Trunk D 10 Sq Cm","41820470","CDM","983","RC","14000","HCPCS","","","facility","both","","","","1928.31","1928.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orchiectomy Simple","41820471","CDM","983","RC","54520","HCPCS","","","facility","both","","","","965.24","965.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mammapl W Prosthetic","41820472","CDM","983","RC","19325","HCPCS","","","facility","both","","","","1941.21","1941.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guide Intraoperative","41820474","CDM","983","RC","76998","HCPCS","","","facility","both","","","","174.74","174.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transperi Needle Place Pros","41820475","CDM","983","RC","55875","HCPCS","","","facility","both","","","","2271.05","2271.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Leg/Ankle Tum < 3 Cm","41820476","CDM","983","RC","27618","HCPCS","","","facility","both","","","","1479.68","1479.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Skin Abd","41820477","CDM","983","RC","15830","HCPCS","","","facility","both","","","","3464.71","3464.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystoscopy Chemodenervation","41820478","CDM","983","RC","52287","HCPCS","","","facility","both","","","","1131.17","1131.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Multi-Comp Penis Pros","41820479","CDM","983","RC","54405","HCPCS","","","facility","both","","","","2368.33","2368.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Ureteroscpy W Renal St","41820480","CDM","983","RC","52346","HCPCS","","","facility","both","","","","1288.15","1288.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystectomy Partial Simple","41820482","CDM","983","RC","51550","HCPCS","","","facility","both","","","","2802.56","2802.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostatectomy Retrpubic Subtot","41820483","CDM","983","RC","55831","HCPCS","","","facility","both","","","","2762.15","2762.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nipple/Areola Reconstruction","41820484","CDM","983","RC","19350","HCPCS","","","facility","both","","","","2537.04","2537.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Excess Skin Tissue Othe","41820485","CDM","983","RC","15839","HCPCS","","","facility","both","","","","2680.52","2680.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr Face/ 7.6-12.5Cm","41820486","CDM","983","RC","12054","HCPCS","","","facility","both","","","","1167.66","1167.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Orbit Flr Fx Periorbit","41820487","CDM","983","RC","21386","HCPCS","","","facility","both","","","","1943.2","1943.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Depr Malar Fx/Zygom Arch","41820488","CDM","983","RC","21360","HCPCS","","","facility","both","","","","1528.21","1528.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Mandibular Fx W Id Fix","41820489","CDM","983","RC","21462","HCPCS","","","facility","both","","","","7010.57","7010.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41820490","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Exc Hip Pelvis Les Sc 3 Cm/>","41820491","CDM","983","RC","27043","HCPCS","","","facility","both","","","","1362.61","1362.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repl Tnl Cvad W Pump","41820492","CDM","983","RC","36583","HCPCS","","","facility","both","","","","4107.95","4107.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transurethral Resectn-Bladder","41820493","CDM","983","RC","52500","HCPCS","","","facility","both","","","","1448.06","1448.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Urethr Strict Filif/Follow","41820494","CDM","983","RC","53620","HCPCS","","","facility","both","","","","457.11","457.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41820496","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41820497","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41820498","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41820500","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41820502","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41820503","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41820504","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41820505","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41820506","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41820508","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41820509","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41820510","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","41820511","CDM","983","RC","99406","HCPCS","","","facility","both","","","","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","41820512","CDM","983","RC","99407","HCPCS","","","facility","both","","","","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Tunica Vaginalis Hydroc","41820513","CDM","983","RC","55060","HCPCS","","","facility","both","","","","1128.54","1128.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41820514","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41820516","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41820517","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41820518","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41820519","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41820520","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41820521","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Litholapaxy In Blad Rem Frag","41820522","CDM","983","RC","52317","HCPCS","","","facility","both","","","","2784.55","2784.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduction/Torsion Testis Surgi","41820524","CDM","983","RC","54600","HCPCS","","","facility","both","","","","1339.05","1339.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clsd Tx Pelvic Ring Fx W/O Man","41820525","CDM","983","RC","27197","HCPCS","","","facility","both","","","","385.66","385.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clsd Tx Pelvic Ring Fx W Manip","41820526","CDM","983","RC","27198","HCPCS","","","facility","both","","","","899.34","899.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoplasty Steno Wo Stnt <1","41820527","CDM","983","RC","31551","HCPCS","","","facility","both","","","","4544.46","4544.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoplasty Steno Wo Stnt 12","41820528","CDM","983","RC","31552","HCPCS","","","facility","both","","","","4390.74","4390.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoplasty Steno W Stnt <12","41820529","CDM","983","RC","31553","HCPCS","","","facility","both","","","","5038.52","5038.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoplasty Steno W Stnt 12+","41820530","CDM","983","RC","31554","HCPCS","","","facility","both","","","","5039.74","5039.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Largsc W/Ther Injection","41820532","CDM","983","RC","31573","HCPCS","","","facility","both","","","","859.74","859.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Largsc W/Njx Augmentation","41820533","CDM","983","RC","31574","HCPCS","","","facility","both","","","","3330.73","3330.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laryngoplasty Medialization","41820534","CDM","983","RC","31591","HCPCS","","","facility","both","","","","3255.64","3255.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cricotracheal Resection","41820535","CDM","983","RC","31592","HCPCS","","","facility","both","","","","5093.28","5093.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath Dialysis Circuit","41820536","CDM","983","RC","36901","HCPCS","","","facility","both","","","","2249.96","2249.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath Dialysis Circuit","41820537","CDM","983","RC","36902","HCPCS","","","facility","both","","","","4266.28","4266.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Cath Dialysis Circ-Stent","41820538","CDM","983","RC","36903","HCPCS","","","facility","both","","","","17260","17260","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmbc/Nfs Dialysis Circuit","41820539","CDM","983","RC","36904","HCPCS","","","facility","both","","","","6304.61","6304.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmbc/Nfs Dialysis Cir-Angiop","41820540","CDM","983","RC","36905","HCPCS","","","facility","both","","","","7934.02","7934.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thrmbc/Nfs Dialysis Circ-Stent","41820541","CDM","983","RC","36906","HCPCS","","","facility","both","","","","21359.76","21359.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Balo Angiop Ctr Dialysis Seg","41820542","CDM","983","RC","36907","HCPCS","","","facility","both","","","","2254.12","2254.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Plmt Ctr Dialysis Seg","41820543","CDM","983","RC","36908","HCPCS","","","facility","both","","","","6981.34","6981.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dialysis Circuit Emboli","41820544","CDM","983","RC","36909","HCPCS","","","facility","both","","","","6650.95","6650.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Esophgl Sphnctr Agmnt","41820545","CDM","983","RC","43284","HCPCS","","","facility","both","","","","1871.22","1871.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Esophgl Sphnctr Dev","41820546","CDM","983","RC","43285","HCPCS","","","facility","both","","","","1924.89","1924.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Largsc W/Laser Dstrj Les","41820547","CDM","983","RC","31572","HCPCS","","","facility","both","","","","1668.55","1668.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Epididymis Testis Scrota","41820548","CDM","983","RC","54700","HCPCS","","","facility","both","","","","631.75","631.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Thigh/Knee Tum Dep 5Cm/>","41820551","CDM","983","RC","27339","HCPCS","","","facility","both","","","","2201.21","2201.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Thigh-Femur Any Lvl","41820552","CDM","983","RC","27590","HCPCS","","","facility","both","","","","2242.52","2242.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explre Retroperitoneal W/Wo Bx","41820553","CDM","983","RC","49010","HCPCS","","","facility","both","","","","2624.75","2624.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rigid Proctosig W Dil","41820554","CDM","983","RC","45303","HCPCS","","","facility","both","","","","3207.19","3207.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fecal Impaction Or Fb","41820555","CDM","983","RC","45915","HCPCS","","","facility","both","","","","1076.14","1076.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Fulgertn Lg Bladder Tumr","41820557","CDM","983","RC","52240","HCPCS","","","facility","both","","","","1132.66","1132.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep Trunk 2.6-7.5Cm","41820558","CDM","983","RC","13101","HCPCS","","","facility","both","","","","1261.06","1261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Lip","41820559","CDM","983","RC","40490","HCPCS","","","facility","both","","","","390.5","390.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Tum 5 Cm Or Less","41820560","CDM","983","RC","49203","HCPCS","","","facility","both","","","","3418.62","3418.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mammary Implant","41820561","CDM","983","RC","19328","HCPCS","","","facility","both","","","","1502.17","1502.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sphincterotomy Anal Div/Sphinc","41820562","CDM","983","RC","46080","HCPCS","","","facility","both","","","","834.35","834.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore For Undescended Testis","41820563","CDM","983","RC","54550","HCPCS","","","facility","both","","","","1451.5","1451.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Mandib Fx W/Multi Approa","41820565","CDM","983","RC","21470","HCPCS","","","facility","both","","","","3520.1","3520.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lcl Surg Wnd/Deh Extens","41820566","CDM","983","RC","13160","HCPCS","","","facility","both","","","","2344.9","2344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit To Determ Ldct Elig","41820567","CDM","983","RC","G0296","HCPCS","","","facility","both","","","","84.72","84.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagus Motility Study","41820568","CDM","983","RC","91010","HCPCS","","","facility","both","","","","648.02","648.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Biopsy Open Deep","41820569","CDM","983","RC","20245","HCPCS","","","facility","both","","","","1007.26","1007.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intestinal Stricturoplasty/Obs","41820570","CDM","983","RC","44615","HCPCS","","","facility","both","","","","3067.22","3067.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduce Volvulus Intussusceptio","41820571","CDM","983","RC","44050","HCPCS","","","facility","both","","","","2667.67","2667.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Renal Tube W/Fluoro","41820573","CDM","983","RC","50389","HCPCS","","","facility","both","","","","1246.35","1246.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Res/Fulg Ortho Uretero","41820574","CDM","983","RC","52300","HCPCS","","","facility","both","","","","809.07","809.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulm  Function Test By Gas","41820576","CDM","983","RC","94727","HCPCS","","","facility","both","","","","139.98","139.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp <5 Yrs","41820577","CDM","983","RC","99151","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","41820578","CDM","983","RC","99152","HCPCS","","","facility","both","","","","164.03","164.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea","41820579","CDM","983","RC","99153","HCPCS","","","facility","both","","","","35.04","35.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp <5 Yrs","41820581","CDM","983","RC","99155","HCPCS","","","facility","both","","","","235.58","235.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp 5/>Yrs","41820582","CDM","983","RC","99156","HCPCS","","","facility","both","","","","220.09","220.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Self-Contd Penis Pros","41820583","CDM","983","RC","54415","HCPCS","","","facility","both","","","","1565.14","1565.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Ea","41820584","CDM","983","RC","99157","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy - Penis","41820585","CDM","983","RC","54100","HCPCS","","","facility","both","","","","623.64","623.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Necr Tiss Genital Perineum","41820586","CDM","983","RC","11004","HCPCS","","","facility","both","","","","1623.28","1623.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Arm/Elbow Tumor <5 Cm","41820587","CDM","983","RC","24076","HCPCS","","","facility","both","","","","1609.89","1609.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Lefort Ii Fx W Fixation","41820588","CDM","983","RC","21345","HCPCS","","","facility","both","","","","2391.61","2391.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Prostate Regrowth","41820589","CDM","983","RC","52630","HCPCS","","","facility","both","","","","1194.08","1194.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Arm/Elbow Les Sc < 3 Cm","41820590","CDM","983","RC","24075","HCPCS","","","facility","both","","","","1624.52","1624.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transurethral Drain Prost Absc","41820591","CDM","983","RC","52700","HCPCS","","","facility","both","","","","1303.03","1303.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap-Nephrectomy W/P Ureterectc","41820592","CDM","983","RC","50546","HCPCS","","","facility","both","","","","3500.49","3500.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Colostomy Complicated","41820593","CDM","983","RC","44345","HCPCS","","","facility","both","","","","3022.74","3022.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Urinary Sys","41820594","CDM","983","RC","53899","HCPCS","","","facility","both","","","","1174.28","1174.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ear Lavage Unilateral","41820595","CDM","983","RC","69209","HCPCS","","","facility","both","","","","47","47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow-Aspirate","41820596","CDM","983","RC","38220","HCPCS","","","facility","both","","","","531.33","531.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow-Bx","41820597","CDM","983","RC","38221","HCPCS","","","facility","both","","","","500.53","500.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Common Digit","41820599","CDM","983","RC","64632","HCPCS","","","facility","both","","","","266.51","266.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Plantar Digit","41820600","CDM","983","RC","64455","HCPCS","","","facility","both","","","","144.9","144.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv Hosp Same Date Iii 55 Min","41820601","CDM","983","RC","99236","HCPCS","","","facility","both","","","","624.59","624.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","41820602","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41820603","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv Hosp Same Date Ii 50 Min","41820604","CDM","983","RC","99235","HCPCS","","","facility","both","","","","485.92","485.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Lesion(S) Penis Simple","41820610","CDM","983","RC","54055","HCPCS","","","facility","both","","","","393.2","393.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41820611","CDM","983","RC","12035","HCPCS","","","facility","both","","","","1198.74","1198.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext Mal+Marg > 4 Cm","41820612","CDM","983","RC","11606","HCPCS","","","facility","both","","","","1367.5","1367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colostomy/Skin Level Cecostomy","41820613","CDM","983","RC","44320","HCPCS","","","facility","both","","","","3438.76","3438.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mastopexy","41820616","CDM","983","RC","19316","HCPCS","","","facility","both","","","","2289.62","2289.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ldct Thorax Lung Ca Screen","41820617","CDM","983","RC","71271","HCPCS","","","facility","both","","","","426.5","426.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Bladder Wound Inj Comp","41820618","CDM","983","RC","51865","HCPCS","","","facility","both","","","","2619.17","2619.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Penil Circumcis Adhes","41820619","CDM","983","RC","54162","HCPCS","","","facility","both","","","","785.1","785.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer","41820620","CDM","983","RC","94640","HCPCS","","","facility","both","","","","58.92","58.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Flap Lower Extremity","41820621","CDM","983","RC","15738","HCPCS","","","facility","both","","","","3816.97","3816.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc I P Ulcer W Ostect Flap","41820623","CDM","983","RC","15946","HCPCS","","","facility","both","","","","4787.49","4787.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body In Scrotum","41820624","CDM","983","RC","55120","HCPCS","","","facility","both","","","","1051.65","1051.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ex Varicocele/Ligate Sprm Vein","41820625","CDM","983","RC","55530","HCPCS","","","facility","both","","","","1043.15","1043.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Meatotomy Except In Newborn","41820626","CDM","983","RC","53020","HCPCS","","","facility","both","","","","282.41","282.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Deep Absc Sft Tiss Nk Thor","41820627","CDM","983","RC","21501","HCPCS","","","facility","both","","","","1463.48","1463.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Te Wo Ins Perm Prosth","41820628","CDM","983","RC","11971","HCPCS","","","facility","both","","","","1528.98","1528.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Stent Plcmt","41820629","CDM","983","RC","45389","HCPCS","","","facility","both","","","","847.28","847.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Laparotomy Expl Celiotomy","41820631","CDM","983","RC","49000","HCPCS","","","facility","both","","","","2205.11","2205.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosigmoidoscpy Rigid Dx","41820632","CDM","983","RC","45300","HCPCS","","","facility","both","","","","395.52","395.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Impl Deep","41820633","CDM","983","RC","20680","HCPCS","","","facility","both","","","","1903.1","1903.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Nephroureteral Cath","41820634","CDM","983","RC","50433","HCPCS","","","facility","both","","","","3769.44","3769.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc-Vestibule/Mouth","41820635","CDM","983","RC","40899","HCPCS","","","facility","both","","","","1253.33","1253.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urethrogram Retrograde","41820636","CDM","983","RC","74450","HCPCS","","","facility","both","","","","47.4","47.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Localization By Xray","41820637","CDM","983","RC","77002","HCPCS","","","facility","both","","","","349.92","349.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Incompl Circumcis","41820638","CDM","983","RC","54163","HCPCS","","","facility","both","","","","651.45","651.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Dentoalveolar","41820639","CDM","983","RC","41899","HCPCS","","","facility","both","","","","1204.88","1204.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mdfc Flap W/Prsrv Vasc Pedcl","41820640","CDM","983","RC","15730","HCPCS","","","facility","both","","","","4718.71","4718.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Musc Myoq Fscq Flp H N Pedcl","41820641","CDM","983","RC","15733","HCPCS","","","facility","both","","","","3084.23","3084.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prep Tum Cav Iort Prtl Mast","41820642","CDM","983","RC","19294","HCPCS","","","facility","both","","","","459.45","459.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nsl/Sins Ndsc W/Artery Lig","41820643","CDM","983","RC","31241","HCPCS","","","facility","both","","","","1279.67","1279.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nsl/Sins Ndsc Total","41820644","CDM","983","RC","31253","HCPCS","","","facility","both","","","","1442.65","1442.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nsl/Sins Ndsc Tot W/Spheno","41820645","CDM","983","RC","31257","HCPCS","","","facility","both","","","","1236.49","1236.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nsl/Sins Ndsc Sphn Tiss Rmvl","41820646","CDM","983","RC","31259","HCPCS","","","facility","both","","","","1360.15","1360.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nsl/Sins Ndsc W/Sins Dilat","41820647","CDM","983","RC","31298","HCPCS","","","facility","both","","","","12045.44","12045.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablate Pulm Tumor Perq Crybl","41820649","CDM","983","RC","32994","HCPCS","","","facility","both","","","","18342.67","18342.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bone Marrow Bx Aspir","41820650","CDM","983","RC","38222","HCPCS","","","facility","both","","","","551.84","551.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Pelvic Lymphadenectomy","41820651","CDM","983","RC","38573","HCPCS","","","facility","both","","","","3364.03","3364.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esphg Tot W/Laps Mobilize","41820652","CDM","983","RC","43286","HCPCS","","","facility","both","","","","8989.2","8989.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esphg Dstl 2/3 W/Lap Moblize","41820653","CDM","983","RC","43287","HCPCS","","","facility","both","","","","10070.39","10070.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esphg Thorascopic Mobilize","41820654","CDM","983","RC","43288","HCPCS","","","facility","both","","","","10638.79","10638.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Tot Hyst Resection Malig","41820656","CDM","983","RC","58575","HCPCS","","","facility","both","","","","5508.8","5508.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tprnl Plmt Biodegrdabl Matrl","41820657","CDM","983","RC","55874","HCPCS","","","facility","both","","","","10309.2","10309.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exercise Test Bronchospasm","41820658","CDM","983","RC","94617","HCPCS","","","facility","both","","","","289.84","289.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pulmonary Stress Testing","41820659","CDM","983","RC","94618","HCPCS","","","facility","both","","","","101.33","101.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dly Ins Breast Prosth Mast","41820660","CDM","983","RC","19342","HCPCS","","","facility","both","","","","2773.24","2773.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Bone Facial Bone S","41820661","CDM","983","RC","21026","HCPCS","","","facility","both","","","","1762.21","1762.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Scrotal Wall Abscess","41820662","CDM","983","RC","55100","HCPCS","","","facility","both","","","","691.28","691.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Interstitial Radioelement","41820664","CDM","983","RC","76965","HCPCS","","","facility","both","","","","283.18","283.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Vasc Procedure","41820665","CDM","983","RC","37799","HCPCS","","","facility","both","","","","633.02","633.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrotal Exploration","41820666","CDM","983","RC","55110","HCPCS","","","facility","both","","","","1148.16","1148.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Breast Les N Loc Ea Addtl","41820667","CDM","983","RC","19126","HCPCS","","","facility","both","","","","448.31","448.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Anal Fistula Complex","41820668","CDM","983","RC","46280","HCPCS","","","facility","both","","","","1426.21","1426.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Maximal Voluntary Ventilation","41820669","CDM","983","RC","94200","HCPCS","","","facility","both","","","","72.67","72.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Total Vital Capcity","41820670","CDM","983","RC","94150","HCPCS","","","facility","both","","","","25.75","25.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Anal Fistula Stage Ii","41820672","CDM","983","RC","46285","HCPCS","","","facility","both","","","","1706.3","1706.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Rect Tum Transanal Part","41820673","CDM","983","RC","45171","HCPCS","","","facility","both","","","","1810.38","1810.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft Trnk/Arm/Leg","41820674","CDM","983","RC","15271","HCPCS","","","facility","both","","","","464.22","464.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft Face/Nk/Hf/G","41820675","CDM","983","RC","15275","HCPCS","","","facility","both","","","","483.09","483.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Lacerated Tongue Flr/Cplx","41820676","CDM","983","RC","41252","HCPCS","","","facility","both","","","","998.15","998.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W/Ureter Stricture Tx","41820677","CDM","983","RC","52341","HCPCS","","","facility","both","","","","822.07","822.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Corporeal Tear","41820678","CDM","983","RC","54437","HCPCS","","","facility","both","","","","1991.3","1991.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Urethral Wnd Penile","41820679","CDM","983","RC","53505","HCPCS","","","facility","both","","","","1432.91","1432.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ex Arm/Elbow Tum Deep 5 Cm/>","41820680","CDM","983","RC","24073","HCPCS","","","facility","both","","","","2034.15","2034.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colectomy Partial Hartmann","41820681","CDM","983","RC","44143","HCPCS","","","facility","both","","","","4746","4746","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mastotomy W Expl Deep","41820682","CDM","983","RC","19020","HCPCS","","","facility","both","","","","1473.78","1473.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Salivary Gland Incisional","41820683","CDM","983","RC","42405","HCPCS","","","facility","both","","","","925.07","925.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Tunneled Ip Cath","41820684","CDM","983","RC","49422","HCPCS","","","facility","both","","","","623.33","623.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Duod/Jejun Tube Perc","41820685","CDM","983","RC","49451","HCPCS","","","facility","both","","","","2374.77","2374.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Paraesoph Her Rpr W/Mesh","41820686","CDM","983","RC","43282","HCPCS","","","facility","both","","","","4894.58","4894.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Enterectomy","41820687","CDM","983","RC","44202","HCPCS","","","facility","both","","","","3945.38","3945.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Grft T/Arm/Lg Child","41820688","CDM","983","RC","15273","HCPCS","","","facility","both","","","","947.45","947.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Sub Grft T/A/L Child Add","41820690","CDM","983","RC","15274","HCPCS","","","facility","both","","","","241.48","241.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Forearm Les Sc 3 Cm/>","41820691","CDM","983","RC","25071","HCPCS","","","facility","both","","","","1248.54","1248.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Enterolysis","41820692","CDM","983","RC","44180","HCPCS","","","facility","both","","","","2624.54","2624.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W Rem Adnexal Structures","41820693","CDM","983","RC","58661","HCPCS","","","facility","both","","","","1885.42","1885.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myomectomy Vag 1-4 Myomas","41820695","CDM","983","RC","58145","HCPCS","","","facility","both","","","","1652.94","1652.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Flap Trunk","41820696","CDM","983","RC","15734","HCPCS","","","facility","both","","","","4385.59","4385.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Ureter Stent Percut","41820698","CDM","983","RC","50382","HCPCS","","","facility","both","","","","3595.37","3595.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc S P Ulcer W 1 Suture","41820699","CDM","983","RC","15931","HCPCS","","","facility","both","","","","2034.4","2034.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpr","41820700","CDM","983","RC","92950","HCPCS","","","facility","both","","","","982.36","982.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracoscopy Diagnostic","41820701","CDM","983","RC","32601","HCPCS","","","facility","both","","","","860.82","860.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Shoulder Sq","41820702","CDM","983","RC","23330","HCPCS","","","facility","both","","","","922.24","922.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Laceration Of Diaphragm","41820703","CDM","983","RC","39501","HCPCS","","","facility","both","","","","2438.4","2438.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl P Wnd Abd Flank","41820704","CDM","983","RC","20102","HCPCS","","","facility","both","","","","1610.92","1610.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Diagnostic Brush Wash","41820706","CDM","983","RC","43235","HCPCS","","","facility","both","","","","890.23","890.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy Decompress","41820707","CDM","983","RC","45337","HCPCS","","","facility","both","","","","335.66","335.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracoscopy W/Pleurodesis","41820709","CDM","983","RC","32650","HCPCS","","","facility","both","","","","1892.08","1892.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Lung Catheter","41820710","CDM","983","RC","32552","HCPCS","","","facility","both","","","","552.44","552.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Leg Decompress Ant/Lat Compart","41820711","CDM","983","RC","27600","HCPCS","","","facility","both","","","","1182.41","1182.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Lungs/Pleura","41820712","CDM","983","RC","32999","HCPCS","","","facility","both","","","","434.97","434.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl P Wnd Chest","41820714","CDM","983","RC","20101","HCPCS","","","facility","both","","","","1511.47","1511.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Cva Dev W Port/Pump","41820715","CDM","983","RC","36576","HCPCS","","","facility","both","","","","1057.3","1057.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy And Biopsy","41820716","CDM","983","RC","45380","HCPCS","","","facility","both","","","","1344.25","1344.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repr Anal Fistula W/Glue","41820717","CDM","983","RC","46706","HCPCS","","","facility","both","","","","519.12","519.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep E N E L 1.1-2.5Cm","41820718","CDM","983","RC","13151","HCPCS","","","facility","both","","","","1320.92","1320.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Lac Mouth Vestib 2.5Cm","41820719","CDM","983","RC","40831","HCPCS","","","facility","both","","","","1130.34","1130.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decortication Pulmonary Total","41820722","CDM","983","RC","32220","HCPCS","","","facility","both","","","","4483.85","4483.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Superf Sft Tiss Bx Thigh/Knee","41820723","CDM","983","RC","27323","HCPCS","","","facility","both","","","","870.33","870.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Enterostomy Lg/Sm Intestine","41820724","CDM","983","RC","44620","HCPCS","","","facility","both","","","","2484.88","2484.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colectomy Prt Sl Cec Colostomy","41820725","CDM","983","RC","44141","HCPCS","","","facility","both","","","","5218.94","5218.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Intestine","41820726","CDM","983","RC","44238","HCPCS","","","facility","both","","","","3696.19","3696.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheostomy Planned","41820727","CDM","983","RC","31600","HCPCS","","","facility","both","","","","872.51","872.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Place Gastrostomy Tube","41820728","CDM","983","RC","43246","HCPCS","","","facility","both","","","","581.61","581.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy Thru Stoma Spx","41820729","CDM","983","RC","44388","HCPCS","","","facility","both","","","","951.72","951.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep Sft Tiss Bx Thigh/Knee","41820730","CDM","983","RC","27324","HCPCS","","","facility","both","","","","1205.07","1205.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Dev Soft Tiss 1St Lesion","41820731","CDM","983","RC","10035","HCPCS","","","facility","both","","","","1487.66","1487.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Exam Of Abdomen","41820732","CDM","983","RC","76705","HCPCS","","","facility","both","","","26","291.62","291.62","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Diagnostic Colonoscopy","41820733","CDM","983","RC","45378","HCPCS","","","facility","both","","","","1027.04","1027.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore/Repair Chest","41820734","CDM","983","RC","32110","HCPCS","","","facility","both","","","","4125.25","4125.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retrograde Pyelogram","41820735","CDM","983","RC","74420","HCPCS","","","facility","both","","","26","235.32","235.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Lap Paraesophag Hernia Repair","41820737","CDM","983","RC","43281","HCPCS","","","facility","both","","","","4359.97","4359.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ep Testis Lesion","41820741","CDM","983","RC","54512","HCPCS","","","facility","both","","","","1583.88","1583.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hip/Pelv Tum Deep < 5 Cm","41820742","CDM","983","RC","27048","HCPCS","","","facility","both","","","","1781.95","1781.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Rec Ing Hernia Any Age Inc","41820743","CDM","983","RC","49521","HCPCS","","","facility","both","","","","2055.62","2055.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Sigmoidoscopy","41820744","CDM","983","RC","45330","HCPCS","","","facility","both","","","","568.9","568.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Lung Bx Addl","41820746","CDM","983","RC","31632","HCPCS","","","facility","both","","","","189.45","189.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Lung Bx Each","41820748","CDM","983","RC","31628","HCPCS","","","facility","both","","","","1148.37","1148.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orbital Implnt Remove Revise","41820749","CDM","983","RC","67560","HCPCS","","","facility","both","","","","3224.45","3224.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transthor Dia Hern Rpr Wo Mesh","41820750","CDM","983","RC","43334","HCPCS","","","facility","both","","","","3496.75","3496.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appy At Time Of Othr Mjr Proc","41820751","CDM","983","RC","44955","HCPCS","","","facility","both","","","","235.05","235.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracoscopy Remov Fb/Fibrin","41820752","CDM","983","RC","32653","HCPCS","","","facility","both","","","","2984.65","2984.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Scrotum","41820753","CDM","983","RC","55150","HCPCS","","","facility","both","","","","1454.79","1454.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colectomy P W Resct Mucofist","41820755","CDM","983","RC","44144","HCPCS","","","facility","both","","","","5034.23","5034.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oophorectomy Part/ Tot Uni","41820756","CDM","983","RC","58940","HCPCS","","","facility","both","","","","1590.75","1590.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Rep S A L Ea Add 5 Cm","41820757","CDM","983","RC","13122","HCPCS","","","facility","both","","","","402.78","402.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Rib Fx W/Fix-Uni","41820758","CDM","983","RC","21811","HCPCS","","","facility","both","","","","1661.52","1661.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Partial Exc Rib","41820764","CDM","983","RC","21600","HCPCS","","","facility","both","","","","1637.62","1637.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Lrg Intest Wo Colostomy","41820765","CDM","983","RC","44604","HCPCS","","","facility","both","","","","3004.64","3004.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Or Bx Temporal Artery","41820766","CDM","983","RC","37609","HCPCS","","","facility","both","","","","958.57","958.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mastectomy Radical","41820767","CDM","983","RC","19305","HCPCS","","","facility","both","","","","3277.98","3277.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Adbomen","41820768","CDM","983","RC","49402","HCPCS","","","facility","both","","","","2448.88","2448.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Bld Vessl Dirct Intra Abd","41820769","CDM","983","RC","35221","HCPCS","","","facility","both","","","","3778.48","3778.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Correct Inverted Nipples","41820771","CDM","983","RC","19355","HCPCS","","","facility","both","","","","2311.42","2311.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Markers","41820772","CDM","983","RC","31626","HCPCS","","","facility","both","","","","2731.15","2731.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Unatt Resp Efft","41820773","CDM","983","RC","95806","HCPCS","","","facility","both","","","26","371.78","371.78","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Excise Hydrocele Sperm Cord Un","41820774","CDM","983","RC","55500","HCPCS","","","facility","both","","","","1160.66","1160.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Bowel To Skin","41820775","CDM","983","RC","44300","HCPCS","","","facility","both","","","","2407.83","2407.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Biopsy(S)","41820776","CDM","983","RC","31625","HCPCS","","","facility","both","","","","1085.77","1085.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Rep Trunk 1.1-2.5Cm","41820777","CDM","983","RC","13100","HCPCS","","","facility","both","","","","1072.59","1072.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Wash","41820778","CDM","983","RC","31622","HCPCS","","","facility","both","","","","750.44","750.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brach-Brach Bp Graft Vn","41820779","CDM","983","RC","35525","HCPCS","","","facility","both","","","","3115.9","3115.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Clear Airways","41820780","CDM","983","RC","31645","HCPCS","","","facility","both","","","","819.19","819.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Abd Perit Omentum Asp Cyst","41820781","CDM","983","RC","49322","HCPCS","","","facility","both","","","","1076.5","1076.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Prostate Volume For Bt","41820782","CDM","983","RC","76873","HCPCS","","","facility","both","","","26","555.69","555.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Urethromeatoplasty W/Mucous Ad","41820783","CDM","983","RC","53450","HCPCS","","","facility","both","","","","1211.23","1211.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","41820784","CDM","983","RC","32555","HCPCS","","","facility","both","","","","995.5","995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove By Ligat Int Hem Grp","41820785","CDM","983","RC","46945","HCPCS","","","facility","both","","","","1027.06","1027.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surg Dx Exam Anorectal","41820786","CDM","983","RC","45990","HCPCS","","","facility","both","","","","306.63","306.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colectomy Tot Abd W Ostomy","41820787","CDM","983","RC","44150","HCPCS","","","facility","both","","","","5366.23","5366.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressng Chg Not For Burn","41820789","CDM","983","RC","15852","HCPCS","","","facility","both","","","","132.72","132.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sedat Endo Service >5Yrs","41820790","CDM","983","RC","G0500","HCPCS","","","facility","both","","","","187.39","187.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Abd Peritoneum","41820791","CDM","983","RC","49999","HCPCS","","","facility","both","","","","220.19","220.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrorrhaphy Sut Perf Gastr","41820792","CDM","983","RC","43840","HCPCS","","","facility","both","","","","3868.78","3868.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Stomach Laparotomy","41820793","CDM","983","RC","43605","HCPCS","","","facility","both","","","","2397.69","2397.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholecystotomy W/Expl Drn/Rem","41820794","CDM","983","RC","47480","HCPCS","","","facility","both","","","","2557.23","2557.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholangiogram Intraop","41820795","CDM","983","RC","74300","HCPCS","","","facility","both","","","","52.02","52.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Place Enteroclysis Tube","41820797","CDM","983","RC","44015","HCPCS","","","facility","both","","","","395.85","395.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Lungs/Pleura","41820798","CDM","983","RC","32999","HCPCS","","","facility","both","","","","1855.08","1855.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Colostomy Simple","41820799","CDM","983","RC","44340","HCPCS","","","facility","both","","","","1820.49","1820.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ostectomy/Sternum Partial","41820800","CDM","983","RC","21620","HCPCS","","","facility","both","","","","1475.56","1475.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Major Artery Chest","41820801","CDM","983","RC","37616","HCPCS","","","facility","both","","","","3116.85","3116.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Px Small Intestine","41820802","CDM","983","RC","44799","HCPCS","","","facility","both","","","","3887.87","3887.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Leg Ankle Deep Absc Hema","41820803","CDM","983","RC","27603","HCPCS","","","facility","both","","","","1650.61","1650.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy Flex W Bx","41820805","CDM","983","RC","45331","HCPCS","","","facility","both","","","","901.33","901.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repl Csf Shunt Valve/Dist Cath","41820806","CDM","983","RC","62230","HCPCS","","","facility","both","","","","2366.97","2366.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appy Rup Appendix Peritonitis","41820807","CDM","983","RC","44960","HCPCS","","","facility","both","","","","2499.43","2499.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Or Repair Testicular In","41820808","CDM","983","RC","54670","HCPCS","","","facility","both","","","","1209.19","1209.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Biliary Drg Cath","41820809","CDM","983","RC","47537","HCPCS","","","facility","both","","","","1479","1479","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Thyroid Cyst/Adenoma","41820810","CDM","983","RC","60200","HCPCS","","","facility","both","","","","1938.64","1938.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Abd Perit Omentum W Bx","41820811","CDM","983","RC","49321","HCPCS","","","facility","both","","","","997.25","997.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debr Necrotiz Stiss - Abd Wall","41820813","CDM","983","RC","11005","HCPCS","","","facility","both","","","","2180.66","2180.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Sm Int W Enterostomy","41820814","CDM","983","RC","44125","HCPCS","","","facility","both","","","","3361.2","3361.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace G-J Tube Perc","41820815","CDM","983","RC","49452","HCPCS","","","facility","both","","","","2892.09","2892.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Abd Peritoneum","41820816","CDM","983","RC","49999","HCPCS","","","facility","both","","","","1768.82","1768.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transurethral Incsn Prostate","41820817","CDM","983","RC","52450","HCPCS","","","facility","both","","","","1396.76","1396.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Full Grft Trnk =<20 Sq Cm","41820818","CDM","983","RC","15200","HCPCS","","","facility","both","","","","2558.93","2558.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drn Ext Ear Abscess Simple","41820819","CDM","983","RC","69000","HCPCS","","","facility","both","","","","589.5","589.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Finger Absc Simple","41820821","CDM","983","RC","26010","HCPCS","","","facility","both","","","","976.06","976.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone Add-On =<20 Sq Cm","41820822","CDM","983","RC","11047","HCPCS","","","facility","both","","","","358.57","358.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Bld Vess Dir Intrathorax","41820823","CDM","983","RC","35216","HCPCS","","","facility","both","","","","5813.94","5813.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Lymphadenectomy Regional","41820825","CDM","983","RC","38747","HCPCS","","","facility","both","","","","745.87","745.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Total Abdominal Hysterectomy","41820826","CDM","983","RC","58150","HCPCS","","","facility","both","","","","2933.9","2933.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Rectovaginal Fist Abd","41820827","CDM","983","RC","57305","HCPCS","","","facility","both","","","","2811.2","2811.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Major Artery Extrem","41820828","CDM","983","RC","37618","HCPCS","","","facility","both","","","","1116.29","1116.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Lip Ft 1 2 V Hgt Compl","41820829","CDM","983","RC","40654","HCPCS","","","facility","both","","","","1801.93","1801.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Intestine","41820830","CDM","983","RC","44238","HCPCS","","","facility","both","","","","2945.03","2945.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/O Imaging","41820831","CDM","983","RC","32554","HCPCS","","","facility","both","","","","704.03","704.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cath Pleura W/ Image","41820832","CDM","983","RC","32557","HCPCS","","","facility","both","","","","2010.25","2010.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Evac Hematom","41820834","CDM","983","RC","61312","HCPCS","","","facility","both","","","","5720.26","5720.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Elevate Depr Sk Fx W Dura Rep","41820835","CDM","983","RC","62010","HCPCS","","","facility","both","","","","4262.27","4262.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sinusotomy Front Oblit Wo Inc","41820836","CDM","983","RC","31081","HCPCS","","","facility","both","","","","3428.97","3428.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Gastrostomy Wo G Tube","41820837","CDM","983","RC","43653","HCPCS","","","facility","both","","","","1674.01","1674.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Superfcl Sft Tiss Bx Leg/Ankle","41820839","CDM","983","RC","27613","HCPCS","","","facility","both","","","","795.42","795.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ntmd Wnd Repair S/A/T/Ext","41820840","CDM","983","RC","12036","HCPCS","","","facility","both","","","","1323.89","1323.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholecystectomy Cholangiogrphy","41820841","CDM","983","RC","47605","HCPCS","","","facility","both","","","","3211.83","3211.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Embedded Fb Mouth Comp","41820842","CDM","983","RC","40805","HCPCS","","","facility","both","","","","937.51","937.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Vulva Perineal Abscess","41820843","CDM","983","RC","56405","HCPCS","","","facility","both","","","","390.63","390.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Si Ulcer Wnd Sgl Perf","41820844","CDM","983","RC","44602","HCPCS","","","facility","both","","","","3984.81","3984.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Peritoneal-Venous Shunt","41820845","CDM","983","RC","49425","HCPCS","","","facility","both","","","","2066.13","2066.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Up Stricture Tx","41820847","CDM","983","RC","52342","HCPCS","","","facility","both","","","","893.16","893.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Open Retroperi Abscess","41820848","CDM","983","RC","49060","HCPCS","","","facility","both","","","","3144.28","3144.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Seton","41820850","CDM","983","RC","46020","HCPCS","","","facility","both","","","","865.99","865.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Init Fem Hernia Reducable","41820851","CDM","983","RC","49553","HCPCS","","","facility","both","","","","1816.82","1816.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Partial Nephrectomy","41820852","CDM","983","RC","50543","HCPCS","","","facility","both","","","","4337.02","4337.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove In/Ex Hem Grp W/Fistu","41820854","CDM","983","RC","46258","HCPCS","","","facility","both","","","","1390.86","1390.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr Face 12.6-20.0Cm","41820855","CDM","983","RC","12055","HCPCS","","","facility","both","","","","1510.58","1510.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna Bx W/O Imgage Ea Add Les","41820856","CDM","983","RC","10004","HCPCS","","","facility","both","","","","152.11","152.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Single Les","41820857","CDM","983","RC","11102","HCPCS","","","facility","both","","","","319.45","319.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Ea Add Les","41820858","CDM","983","RC","11103","HCPCS","","","facility","both","","","","168.71","168.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","41820859","CDM","983","RC","11104","HCPCS","","","facility","both","","","","402.35","402.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Add Les","41820860","CDM","983","RC","11105","HCPCS","","","facility","both","","","","192.32","192.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incisional Bx Skin Single Les","41820862","CDM","983","RC","11106","HCPCS","","","facility","both","","","","488.15","488.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Ea Add Les","41820863","CDM","983","RC","11107","HCPCS","","","facility","both","","","","228.66","228.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep G Tube No Tract Revision","41820864","CDM","983","RC","43762","HCPCS","","","facility","both","","","","745.38","745.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep G Tube W Tract Revision","41820865","CDM","983","RC","43763","HCPCS","","","facility","both","","","","1102.92","1102.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Existing Trct Endourolgc","41820866","CDM","983","RC","50436","HCPCS","","","facility","both","","","","442.26","442.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Exst Trc-New Access Rcs","41820867","CDM","983","RC","50437","HCPCS","","","facility","both","","","","735.96","735.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transurethrl Destr Prst Tiss","41820868","CDM","983","RC","53854","HCPCS","","","facility","both","","","","5937.31","5937.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simp Rep Sclp/Nk/Gnt/Trk>30Cm","41820869","CDM","983","RC","12007","HCPCS","","","facility","both","","","","685.96","685.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Trach Wnd Inj Cervical","41820870","CDM","983","RC","31800","HCPCS","","","facility","both","","","","2179.38","2179.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Major Artery Neck","41820871","CDM","983","RC","37615","HCPCS","","","facility","both","","","","1528.98","1528.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostatectomy Retropub W Ln Bx","41820872","CDM","983","RC","55842","HCPCS","","","facility","both","","","","3416.03","3416.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Ext Fix Sys W Anesth","41820873","CDM","983","RC","20694","HCPCS","","","facility","both","","","","1317.29","1317.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lymph Or Ln Nm Scan","41820874","CDM","983","RC","78195","HCPCS","","","facility","both","","","","1179.12","1179.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Brush","41820875","CDM","983","RC","31623","HCPCS","","","facility","both","","","","843.96","843.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Gastro Intub W/Asp","41820876","CDM","983","RC","43753","HCPCS","","","facility","both","","","","61.72","61.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Sclerosing Sol Hemorrhoids","41820877","CDM","983","RC","46500","HCPCS","","","facility","both","","","","963.46","963.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrectmy W Gastrojejunostmy","41820878","CDM","983","RC","43632","HCPCS","","","facility","both","","","","5748.33","5748.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Tum Over 10 Cm","41820880","CDM","983","RC","49205","HCPCS","","","facility","both","","","","4974.57","4974.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy W Bleed Control","41820881","CDM","983","RC","46614","HCPCS","","","facility","both","","","","470.81","470.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","41820882","CDM","983","RC","97597","HCPCS","","","facility","both","","","","306.75","306.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem Add 20 Cm/<","41820883","CDM","983","RC","97598","HCPCS","","","facility","both","","","","141.66","141.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep I D Ua Elbow","41820884","CDM","983","RC","23930","HCPCS","","","facility","both","","","","1117.4","1117.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Rectum/Remove Sigmoid","41820885","CDM","983","RC","45550","HCPCS","","","facility","both","","","","4226.37","4226.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Salpingo-Oophorectmy  Uni/Bil","41820886","CDM","983","RC","58720","HCPCS","","","facility","both","","","","2177.45","2177.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Upr/L Xtremity Art 2 Levels","41820887","CDM","983","RC","93922","HCPCS","","","facility","both","","","TC","278.29","278.29","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
"Endoscopic Pancreatoscopy","41820888","CDM","983","RC","43273","HCPCS","","","facility","both","","","","349.79","349.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Rep Face 20.1-30.0Cm","41820889","CDM","983","RC","12056","HCPCS","","","facility","both","","","","1773.37","1773.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pancreatorrhaphy For Injury","41820890","CDM","983","RC","48545","HCPCS","","","facility","both","","","","3834.54","3834.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cricopharyngeal Myotomy","41820891","CDM","983","RC","43030","HCPCS","","","facility","both","","","","1526.92","1526.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrectmy Tot Roux En Y Recon","41820892","CDM","983","RC","43621","HCPCS","","","facility","both","","","","6401.52","6401.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Lumbar Hernia","41820893","CDM","983","RC","49540","HCPCS","","","facility","both","","","","1937.84","1937.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrn Colonoscopy-Not Hi Risk","41820894","CDM","983","RC","G0121","HCPCS","","","facility","both","","","","1027.51","1027.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Rectovaginal Fistula Vag","41820897","CDM","983","RC","57300","HCPCS","","","facility","both","","","","1748.53","1748.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nephrectomy Comp Prev Surg","41820898","CDM","983","RC","50225","HCPCS","","","facility","both","","","","3484.72","3484.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemorrhage Simple Liver Suture","41820900","CDM","983","RC","47350","HCPCS","","","facility","both","","","","3916.29","3916.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Blood Vessel Direct Upr","41820901","CDM","983","RC","35206","HCPCS","","","facility","both","","","","2192.92","2192.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrostomy Opn Wo Gastric Tub","41820902","CDM","983","RC","43830","HCPCS","","","facility","both","","","","2029.56","2029.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Insertion Perm Ip Cath","41820904","CDM","983","RC","49324","HCPCS","","","facility","both","","","","1113.14","1113.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Trachea/Bronchi Proc","41820905","CDM","983","RC","31899","HCPCS","","","facility","both","","","","99.68","99.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mammary Impl Material","41820906","CDM","983","RC","19330","HCPCS","","","facility","both","","","","1895.68","1895.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Liver Hem Re Expl Wnd Rem Pack","41820907","CDM","983","RC","47362","HCPCS","","","facility","both","","","","4148.04","4148.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Rapid Flu","41820908","CDM","300","RC","87804","HCPCS","","","facility","both","","","QW","38","38","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Dilate Female Urethra Initial","41820909","CDM","983","RC","53660","HCPCS","","","facility","both","","","","219.85","219.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dil Ureth Stricture Male Init","41820910","CDM","983","RC","53600","HCPCS","","","facility","both","","","","255.59","255.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sq Hormone Pellet Impl","41820912","CDM","983","RC","11980","HCPCS","","","facility","both","","","","288.86","288.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nasal /Orogastric W/Tube Plmt","41820913","CDM","983","RC","43752","HCPCS","","","facility","both","","","","117.6","117.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trach Tube Chg Pre Fistula","41820914","CDM","983","RC","31502","HCPCS","","","facility","both","","","","100.58","100.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Stomach","41820915","CDM","983","RC","43659","HCPCS","","","facility","both","","","","2517.13","2517.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgical Closure-Gastrostomy","41820916","CDM","983","RC","43870","HCPCS","","","facility","both","","","","2043.18","2043.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sternal Debridement","41820917","CDM","983","RC","21627","HCPCS","","","facility","both","","","","1589.98","1589.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Abdomen Musculoskel","41820918","CDM","983","RC","22999","HCPCS","","","facility","both","","","","1404.23","1404.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Uro Sphincter","41820920","CDM","983","RC","53446","HCPCS","","","facility","both","","","","1892.66","1892.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tot Disc Arthr 1 Intrspc Limbr","41820921","CDM","983","RC","22857","HCPCS","","","facility","both","","","","5168.52","5168.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Prep Addl 100 Cm","41820922","CDM","983","RC","15003","HCPCS","","","facility","both","","","","220.01","220.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Deep Fb Thigh Or Knee","41820923","CDM","983","RC","27372","HCPCS","","","facility","both","","","","1875.66","1875.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Exc/Destr Les Ovary/Pelvic","41820924","CDM","983","RC","58662","HCPCS","","","facility","both","","","","2068.45","2068.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehis W Pack","41820925","CDM","983","RC","12021","HCPCS","","","facility","both","","","","522.4","522.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Create Shunt Ventriculo Perit","41820926","CDM","983","RC","62223","HCPCS","","","facility","both","","","","2940.44","2940.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Hydrocele Bilateral","41820927","CDM","983","RC","55041","HCPCS","","","facility","both","","","","1510.03","1510.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureteroneocystostomy Vp Hitch","41820928","CDM","983","RC","50785","HCPCS","","","facility","both","","","","3527.56","3527.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41820929","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheostomy Emerg Transtrachl","41820930","CDM","983","RC","31603","HCPCS","","","facility","both","","","","912.46","912.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Remove Foreign Body","41820931","CDM","983","RC","43247","HCPCS","","","facility","both","","","","1169.53","1169.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginal Hysterectomy =<250 Gm","41820932","CDM","983","RC","58260","HCPCS","","","facility","both","","","","2435.83","2435.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Biopsy Open Superficial","41820933","CDM","983","RC","20240","HCPCS","","","facility","both","","","","425.34","425.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tt Ndl Wire/Dilator/Stnt-O2 Tx","41820934","CDM","983","RC","31730","HCPCS","","","facility","both","","","","3940.21","3940.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Revision Perm Ip Cath","41820935","CDM","983","RC","49325","HCPCS","","","facility","both","","","","1184.02","1184.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Abd Perit","41820936","CDM","983","RC","49329","HCPCS","","","facility","both","","","","500.1","500.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41820937","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompr Farm/Wrist W Debridem","41820938","CDM","983","RC","25023","HCPCS","","","facility","both","","","","3637.63","3637.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompr Fasciotomy Hand","41820939","CDM","983","RC","26037","HCPCS","","","facility","both","","","","1689.89","1689.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehisc Smpl","41820940","CDM","983","RC","12020","HCPCS","","","facility","both","","","","917.11","917.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Df Leg Ant Lat P Compartm","41820941","CDM","983","RC","27602","HCPCS","","","facility","both","","","","1382.78","1382.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy Thru Stoma W Bx","41820942","CDM","983","RC","44389","HCPCS","","","facility","both","","","","1274.45","1274.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Of Inf Vena Cava","41820943","CDM","983","RC","37619","HCPCS","","","facility","both","","","","4859.87","4859.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Major Artery Abdomen","41820944","CDM","983","RC","37617","HCPCS","","","facility","both","","","","3740.86","3740.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41820945","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Of Common Iliac Vein","41820946","CDM","983","RC","37660","HCPCS","","","facility","both","","","","3719.4","3719.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Chest Heart Massage","41820947","CDM","983","RC","32160","HCPCS","","","facility","both","","","","2256.66","2256.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 3.1-4C","41820948","CDM","983","RC","11604","HCPCS","","","facility","both","","","","970.41","970.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Partial Removal Of Lung","41820949","CDM","983","RC","32480","HCPCS","","","facility","both","","","","4138.54","4138.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair N-Hf/Genit","41820950","CDM","983","RC","12045","HCPCS","","","facility","both","","","","1263.73","1263.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Srep S N A G Tr E 20.1-30.0Cm","41820951","CDM","983","RC","12006","HCPCS","","","facility","both","","","","604.46","604.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41820952","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Repair E N E L 2.6-7.5Cm","41820953","CDM","983","RC","13152","HCPCS","","","facility","both","","","","1561.4","1561.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comp Rep E N E L Ea Add 5 Cm","41820954","CDM","983","RC","13153","HCPCS","","","facility","both","","","","576.52","576.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vasc Embolize/Occlude Bleed","41820955","CDM","983","RC","37244","HCPCS","","","facility","both","","","","23581.39","23581.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evaluate Pt Use Of Inhaler","41820956","CDM","983","RC","94664","HCPCS","","","facility","both","","","","55.34","55.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb From Deep Penile Tissue","41820957","CDM","983","RC","54115","HCPCS","","","facility","both","","","","1360.27","1360.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Uret Cath Brush Bx","41820958","CDM","983","RC","52007","HCPCS","","","facility","both","","","","1524.37","1524.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cabg Arterial Graft 1 Artery","41820959","CDM","983","RC","33533","HCPCS","","","facility","both","","","","5210.51","5210.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41820960","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cabg Artery-Vein 2","41820961","CDM","983","RC","33518","HCPCS","","","facility","both","","","","1130.89","1130.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Vein Harvest For Cabg","41820962","CDM","983","RC","33508","HCPCS","","","facility","both","","","","45.04","45.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Monitor Interst Fld Pressure","41820963","CDM","983","RC","20950","HCPCS","","","facility","both","","","","843.78","843.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Abd Omental Flap","41820964","CDM","983","RC","49905","HCPCS","","","facility","both","","","","991.2","991.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Wedge/Bx Lung Nodule","41820965","CDM","983","RC","32097","HCPCS","","","facility","both","","","","2254.7","2254.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Anal Fissure","41820966","CDM","983","RC","46200","HCPCS","","","facility","both","","","","1461.78","1461.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inst Tun Ip Cath For Dial Open","41820967","CDM","983","RC","49421","HCPCS","","","facility","both","","","","637.29","637.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Tail Bone","41820968","CDM","983","RC","27080","HCPCS","","","facility","both","","","","1463.89","1463.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debrd Necrotiz Tiss-Gent/Peri","41820969","CDM","983","RC","11006","HCPCS","","","facility","both","","","","1983.63","1983.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pericardiotomy-Rem Clot/Fb","41820970","CDM","983","RC","33020","HCPCS","","","facility","both","","","","2317.35","2317.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Av Fistula - Graft","41820971","CDM","983","RC","36832","HCPCS","","","facility","both","","","","2109.99","2109.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Proc For Peyronie Disease","41820972","CDM","983","RC","54200","HCPCS","","","facility","both","","","","346.67","346.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Pelv Hip Jnt Absc Deep","41820973","CDM","983","RC","26990","HCPCS","","","facility","both","","","","1970.16","1970.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abdl Tum Deep 5 Cm/>","41820975","CDM","983","RC","22901","HCPCS","","","facility","both","","","","1930.14","1930.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep I D Absc Farm Wrist","41820976","CDM","983","RC","25028","HCPCS","","","facility","both","","","","1849.78","1849.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Up Arm Or Elbow Sq","41820977","CDM","983","RC","24200","HCPCS","","","facility","both","","","","679.88","679.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41820978","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Ileostomy Complicated","41820979","CDM","983","RC","44314","HCPCS","","","facility","both","","","","2898.83","2898.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Att Trunk D 10.1 30 Sq","41820980","CDM","983","RC","14001","HCPCS","","","facility","both","","","","2432.48","2432.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct B9 Lesion 1-14","41820981","CDM","983","RC","17110","HCPCS","","","facility","both","","","","358","358","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destr Lesion Penis Extensive","41820982","CDM","983","RC","54065","HCPCS","","","facility","both","","","","678.41","678.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Rectum","41820983","CDM","983","RC","45999","HCPCS","","","facility","both","","","","1849.4","1849.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41820986","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41820994","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41821000","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Band Ligation","41821003","CDM","983","RC","45350","HCPCS","","","facility","both","","","","2074.42","2074.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrv Block,Other Peripheral","41821004","CDM","983","RC","64450","HCPCS","","","facility","both","","","","238.14","238.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splenectmy Tot En Bloc Disease","41821005","CDM","983","RC","38102","HCPCS","","","facility","both","","","","735.7","735.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mgmt Lvr Hemrg Cplx Sutr Injry","41821006","CDM","983","RC","47360","HCPCS","","","facility","both","","","","5336.87","5336.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Esophagus","41821007","CDM","983","RC","43289","HCPCS","","","facility","both","","","","3000.13","3000.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Stomach","41821009","CDM","983","RC","43659","HCPCS","","","facility","both","","","","5229.31","5229.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Hernia","41821010","CDM","983","RC","49659","HCPCS","","","facility","both","","","","4261.19","4261.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Removal Of Rectum","41821011","CDM","983","RC","45395","HCPCS","","","facility","both","","","","5695.11","5695.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W/Adrealectmy/Exp Adr Glnd","41821012","CDM","983","RC","60650","HCPCS","","","facility","both","","","","3400.68","3400.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj Intercost Mlt","41821013","CDM","983","RC","64421","HCPCS","","","facility","both","","","","101.82","101.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prepertnl Pel Pack Hemrrg Trma","41821015","CDM","983","RC","49013","HCPCS","","","facility","both","","","","1240.27","1240.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reexploration Pelvic Wound","41821016","CDM","983","RC","49014","HCPCS","","","facility","both","","","","1030.82","1030.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Hernia","41821017","CDM","983","RC","49659","HCPCS","","","facility","both","","","","1625.73","1625.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Intestine","41821019","CDM","983","RC","44238","HCPCS","","","facility","both","","","","307.79","307.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Chole W/Exploration Of Cd","41821020","CDM","983","RC","47564","HCPCS","","","facility","both","","","","3190.82","3190.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Orbit Flr Fx Comb Appr","41821021","CDM","983","RC","21387","HCPCS","","","facility","both","","","","2350.13","2350.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Surgical Jejunostomy","41821022","CDM","983","RC","44186","HCPCS","","","facility","both","","","","1870.87","1870.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Biopsy Single/Multiple","41821023","CDM","983","RC","43239","HCPCS","","","facility","both","","","","1198.8","1198.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Bx/Exc Inguinofem Nodes","41821024","CDM","983","RC","38531","HCPCS","","","facility","both","","","","1274.14","1274.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Soft Tissue Shoulder Deep","41821025","CDM","983","RC","23066","HCPCS","","","facility","both","","","","1787.65","1787.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41821026","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc/Repl Spine Nstim Pg/Rcvr","41821027","CDM","983","RC","63685","HCPCS","","","facility","both","","","","1055.18","1055.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grafting Auto Fat Lipo 50 Cc/<","41821028","CDM","983","RC","15771","HCPCS","","","facility","both","","","","1752.34","1752.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Auto Fat Lipo Ea Add 50Cc","41821029","CDM","983","RC","15772","HCPCS","","","facility","both","","","","540.03","540.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suspension Of Testis","41821030","CDM","983","RC","54620","HCPCS","","","facility","both","","","","880.17","880.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Lesn Meniscus/Capsule Knee","41821031","CDM","983","RC","27347","HCPCS","","","facility","both","","","","1539.75","1539.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gstrt P Dst W/Gastrduodenostmy","41821032","CDM","983","RC","43631","HCPCS","","","facility","both","","","","4038.87","4038.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrotomy Sut Rep Bleed Ulcer","41821033","CDM","983","RC","43501","HCPCS","","","facility","both","","","","3755.31","3755.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41821034","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fasciotomy Hip/Thigh Any Type","41821035","CDM","983","RC","27025","HCPCS","","","facility","both","","","","2709.6","2709.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hip/Pelv Tum Deep 5 Cm/>","41821036","CDM","983","RC","27045","HCPCS","","","facility","both","","","","2104.5","2104.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Foot Transmetatarsal","41821037","CDM","983","RC","28805","HCPCS","","","facility","both","","","","2101.41","2101.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Transf Uarm Shldr Sgl","41821038","CDM","983","RC","23395","HCPCS","","","facility","both","","","","3692.81","3692.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Part Colectomy W/Stoma","41821039","CDM","983","RC","44206","HCPCS","","","facility","both","","","","4890.49","4890.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Leg Tib Fib Op Circlr","41821040","CDM","983","RC","27882","HCPCS","","","facility","both","","","","1696.98","1696.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41821042","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41821043","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41821044","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41821045","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41821046","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41821047","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41821048","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41821049","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41821050","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41821051","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41821053","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41821054","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41821055","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 30M","41821056","CDM","983","RC","G0425","HCPCS","","","facility","both","","","95","281.76","281.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 50M","41821057","CDM","983","RC","G0426","HCPCS","","","facility","both","","","95","383.76","383.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 70M","41821058","CDM","983","RC","G0427","HCPCS","","","facility","both","","","95","568.44","568.44","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Office Consult Lvl V","41821059","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Esoph Lengthening","41821060","CDM","983","RC","43283","HCPCS","","","facility","both","","","","439.11","439.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Penis Partial","41821061","CDM","983","RC","54120","HCPCS","","","facility","both","","","","1816.38","1816.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Consult Level Ii","41821063","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41821064","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41821065","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41821066","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"I D Absc Smpl Or Sgl","41821067","CDM","983","RC","10060","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Pelvis Or Hip Deep","41821068","CDM","983","RC","27087","HCPCS","","","facility","both","","","","1766.81","1766.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","41821069","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41821070","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41821071","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41821072","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41821073","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41821074","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Remove Foreign Body Simple","41821075","CDM","983","RC","10120","HCPCS","","","facility","both","","","","479.72","479.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alc/Sub Intrv >30","41821076","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41821077","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Lap W Retrop Ln Bx Single Mult","41821078","CDM","983","RC","38570","HCPCS","","","facility","both","","","","1454.55","1454.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Pleurodesis W/Agent","41821079","CDM","983","RC","32560","HCPCS","","","facility","both","","","","805.46","805.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Proctopexy Prolpse","41821080","CDM","983","RC","45400","HCPCS","","","facility","both","","","","3220.22","3220.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enteroenterostomy Anast Intest","41821081","CDM","983","RC","44130","HCPCS","","","facility","both","","","","3670.95","3670.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hand Tum Deep 1.5 Cm/>","41821082","CDM","983","RC","26113","HCPCS","","","facility","both","","","","1640.92","1640.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","41821083","CDM","983","RC","10140","HCPCS","","","facility","both","","","","530.14","530.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Orbit Fx Not Bo W Impl","41821084","CDM","983","RC","21407","HCPCS","","","facility","both","","","","1887.68","1887.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appendectomy","41821085","CDM","983","RC","44950","HCPCS","","","facility","both","","","","1797.66","1797.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk > 2.0 Cm","41821086","CDM","983","RC","11303","HCPCS","","","facility","both","","","","489.38","489.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Lymphadenectomy","41821087","CDM","983","RC","38724","HCPCS","","","facility","both","","","","4121.7","4121.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Surg Splenectomy","41821088","CDM","983","RC","38120","HCPCS","","","facility","both","","","","2950.13","2950.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Stomach","41821089","CDM","983","RC","43999","HCPCS","","","facility","both","","","","161.56","161.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Ext Hem Groups 2+","41821090","CDM","983","RC","46250","HCPCS","","","facility","both","","","","1437.83","1437.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","41821091","CDM","983","RC","10160","HCPCS","","","facility","both","","","","406.03","406.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Nephrostogram Ureterogrm","41821092","CDM","983","RC","50430","HCPCS","","","facility","both","","","","1790.79","1790.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Rmvl Adj Gastric All Parts","41821093","CDM","983","RC","43774","HCPCS","","","facility","both","","","","2685.06","2685.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clsd Intestinal Cutaneous Fist","41821094","CDM","983","RC","44640","HCPCS","","","facility","both","","","","3896.34","3896.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Ileo/Jejuno-Stomy","41821095","CDM","983","RC","44187","HCPCS","","","facility","both","","","","3199.88","3199.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Fb Removal","41821096","CDM","983","RC","45332","HCPCS","","","facility","both","","","","820.01","820.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy For Bleeding","41821097","CDM","983","RC","44391","HCPCS","","","facility","both","","","","2112.89","2112.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cholecystectomy With Expl Cbd","41821098","CDM","983","RC","47610","HCPCS","","","facility","both","","","","3500.87","3500.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Endoscopic Stent Place","41821099","CDM","983","RC","43266","HCPCS","","","facility","both","","","","634.94","634.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recon Extrahep Bili Duct W/Ana","41821100","CDM","983","RC","47800","HCPCS","","","facility","both","","","","4409.43","4409.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colotomy-Explore Bx Fb Rem","41821101","CDM","983","RC","44025","HCPCS","","","facility","both","","","","2749.17","2749.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transect/Avulse Oth Spinal Nrv","41821102","CDM","983","RC","64772","HCPCS","","","facility","both","","","","1670.3","1670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Tmj Dislocation Initial","41821103","CDM","983","RC","21480","HCPCS","","","facility","both","","","","377.94","377.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Frenulotomy Of Penis","41821104","CDM","983","RC","54164","HCPCS","","","facility","both","","","","565.78","565.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 5 10 Mins","41821105","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.7","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41821106","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.71","86.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41821107","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Salpingectomy Compl/Part Un","41821108","CDM","983","RC","58700","HCPCS","","","facility","both","","","","2301.54","2301.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Ext Eczema/Infect Skin","41821109","CDM","983","RC","11000","HCPCS","","","facility","both","","","","175.41","175.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Postop Hemor Thromb Inf A","41821110","CDM","983","RC","35840","HCPCS","","","facility","both","","","","3386.09","3386.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Non-Tunneled Cv Cath","41821111","CDM","983","RC","36580","HCPCS","","","facility","both","","","","682.25","682.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Inf/Rem Fb - Elbow","41821112","CDM","983","RC","24000","HCPCS","","","facility","both","","","","1434.28","1434.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closed Ev Fistula W/Int Resect","41821113","CDM","983","RC","44661","HCPCS","","","facility","both","","","","4322.84","4322.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureteroneocystostomy Uret Bldr","41821114","CDM","983","RC","50780","HCPCS","","","facility","both","","","","3149.1","3149.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Appendix","41821115","CDM","983","RC","44979","HCPCS","","","facility","both","","","","1693.14","1693.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Tx Female Ureth Syndrome","41821116","CDM","983","RC","52285","HCPCS","","","facility","both","","","","972.94","972.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Ureter Stent Percut","41821118","CDM","983","RC","50384","HCPCS","","","facility","both","","","","2830.32","2830.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj For Cystogram","41821119","CDM","983","RC","51600","HCPCS","","","facility","both","","","","654.82","654.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urography Antegrade Rs I","41821120","CDM","983","RC","74425","HCPCS","","","facility","both","","","","410.04","410.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Create Pericardial Window/Part","41821121","CDM","983","RC","33025","HCPCS","","","facility","both","","","","2164.73","2164.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Cardiac Wound Wo Cpb","41821122","CDM","983","RC","33300","HCPCS","","","facility","both","","","","6801.4","6801.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enterotomy Bx-Exp-Fbr Sm Int","41821123","CDM","983","RC","44020","HCPCS","","","facility","both","","","","2718.15","2718.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Leg/Ankle Les Sc 3 Cm/>","41821124","CDM","983","RC","27632","HCPCS","","","facility","both","","","","1185.74","1185.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Myomectomy=<250Gm","41821126","CDM","983","RC","58545","HCPCS","","","facility","both","","","","2609.66","2609.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Samplng 1/2 Node","41821127","CDM","983","RC","31652","HCPCS","","","facility","both","","","","3609.82","3609.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W/Omentopexy Add-On","41821128","CDM","983","RC","49326","HCPCS","","","facility","both","","","","515.67","515.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove By Ligat Int Hem 2+ Grp","41821129","CDM","983","RC","46946","HCPCS","","","facility","both","","","","1149.17","1149.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Foreskin Manipulation","41821130","CDM","983","RC","54450","HCPCS","","","facility","both","","","","203.75","203.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Exam Abdo Back Wall Lim","41821131","CDM","983","RC","76775","HCPCS","","","facility","both","","","26","183.27","183.27","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Endoscopic Us Exam Esoph","41821132","CDM","983","RC","43237","HCPCS","","","facility","both","","","","574.69","574.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Skin Tags 15 Lesions","41821133","CDM","983","RC","11200","HCPCS","","","facility","both","","","","277.28","277.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompress Frarm Wrist 1 Comp","41821134","CDM","983","RC","25020","HCPCS","","","facility","both","","","","1930.68","1930.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Sampling 3/> Node","41821135","CDM","983","RC","31653","HCPCS","","","facility","both","","","","3756.98","3756.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Soft Tiss Bx Back Flank Superf","41821136","CDM","983","RC","21920","HCPCS","","","facility","both","","","","785.79","785.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Multi-Comp Penis Pros","41821137","CDM","983","RC","54406","HCPCS","","","facility","both","","","","2100.22","2100.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Sacrl Pr Ulcer W/Ostectomy","41821138","CDM","983","RC","15933","HCPCS","","","facility","both","","","","2489.75","2489.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tracheobronch Via Old Incision","41821139","CDM","983","RC","31615","HCPCS","","","facility","both","","","","526.21","526.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Bladder","41821140","CDM","983","RC","51999","HCPCS","","","facility","both","","","","2458.71","2458.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Tags Ea Add'l 10","41821141","CDM","983","RC","11201","HCPCS","","","facility","both","","","","55.11","55.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Pilonid Cyst Smpl","41821142","CDM","983","RC","11770","HCPCS","","","facility","both","","","","992.49","992.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Ileostomy Simple","41821143","CDM","983","RC","44312","HCPCS","","","facility","both","","","","1540.16","1540.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ovarian Cystectomy Unilater","41821144","CDM","983","RC","58925","HCPCS","","","facility","both","","","","2208.32","2208.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Male Genital Sys","41821145","CDM","983","RC","55899","HCPCS","","","facility","both","","","","1175.88","1175.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Gastric Bypass/Roux-En-Y","41821146","CDM","983","RC","43644","HCPCS","","","facility","both","","","","4367.49","4367.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41821147","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastrojejunostomy Wo Vagotomy","41821148","CDM","983","RC","43820","HCPCS","","","facility","both","","","","3655.45","3655.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orchiectomy Partial","41821149","CDM","983","RC","54522","HCPCS","","","facility","both","","","","1646.3","1646.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion 2-4","41821150","CDM","983","RC","11056","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft T/A/L Add 25 Sc","41821151","CDM","983","RC","15272","HCPCS","","","facility","both","","","","78.31","78.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft F/N/Hf/Gnt Addl","41821152","CDM","983","RC","15276","HCPCS","","","facility","both","","","","100.82","100.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gft Skn Sub F/S/E >/=100Cm","41821153","CDM","983","RC","15277","HCPCS","","","facility","both","","","","1034.66","1034.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abrasion Single Lesion","41821154","CDM","983","RC","15786","HCPCS","","","facility","both","","","","761.66","761.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abrasion Lesion Ea Add'l 4/<","41821155","CDM","983","RC","15787","HCPCS","","","facility","both","","","","128.98","128.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Paste/Unna Boot","41821156","CDM","983","RC","29580","HCPCS","","","facility","both","","","","197.64","197.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Multlay Comprs Lwr Leg","41821157","CDM","983","RC","29581","HCPCS","","","facility","both","","","","289.33","289.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 0.6-1Cm","41821158","CDM","983","RC","11301","HCPCS","","","facility","both","","","","386.58","386.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Grft F/N/Hf Ea Add 100Sqcm","41821159","CDM","983","RC","15278","HCPCS","","","facility","both","","","","282.63","282.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thigh Femur Re Amputation","41821160","CDM","983","RC","27596","HCPCS","","","facility","both","","","","2049.67","2049.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Thigh-Femur Circular","41821161","CDM","983","RC","27592","HCPCS","","","facility","both","","","","1927.98","1927.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Bx Hip Pelvis Deep","41821162","CDM","983","RC","27041","HCPCS","","","facility","both","","","","1991.14","1991.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Orbit Fx Not Bo Wo Imp","41821163","CDM","983","RC","21406","HCPCS","","","facility","both","","","","1677.49","1677.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Op Tx Mandibular Fx Wo Id Fix","41821164","CDM","983","RC","21461","HCPCS","","","facility","both","","","","6170.61","6170.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Intestine 1+ Lesion(S)","41821165","CDM","983","RC","44110","HCPCS","","","facility","both","","","","2335.32","2335.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 1.1-2Cm","41821166","CDM","983","RC","11302","HCPCS","","","facility","both","","","","446.48","446.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decom Fa Wrist Flex Ext W Deb","41821167","CDM","983","RC","25025","HCPCS","","","facility","both","","","","3335.96","3335.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace G/C Tube Perc","41821168","CDM","983","RC","49450","HCPCS","","","facility","both","","","","2108.75","2108.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Xray Control Catheter Change","41821169","CDM","983","RC","75984","HCPCS","","","facility","both","","","26","317.99","317.99","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Laparoscopy Pyeloplasty","41821170","CDM","983","RC","50544","HCPCS","","","facility","both","","","","3419.84","3419.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep St Bx - Ua Or Elbow","41821171","CDM","983","RC","24066","HCPCS","","","facility","both","","","","1900.2","1900.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Ischiorectal","41821172","CDM","983","RC","46060","HCPCS","","","facility","both","","","","9419.74","9419.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Tunneled Cv Cath","41821173","CDM","983","RC","36581","HCPCS","","","facility","both","","","","2632.45","2632.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck .6-1Cm","41821174","CDM","983","RC","11306","HCPCS","","","facility","both","","","","391.33","391.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subtotal Abd Hysterectomy","41821175","CDM","983","RC","58180","HCPCS","","","facility","both","","","","2789.79","2789.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Gastroplasty","41821176","CDM","983","RC","43848","HCPCS","","","facility","both","","","","5239.43","5239.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Paraesoph Hiat Her Wo Mesh","41821177","CDM","983","RC","43332","HCPCS","","","facility","both","","","","3118.58","3118.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap New Ureter W/Cystoscopy","41821178","CDM","983","RC","50947","HCPCS","","","facility","both","","","","3818.06","3818.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abdominal Paracentesis","41821179","CDM","983","RC","49082","HCPCS","","","facility","both","","","","655.77","655.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Electrd/Pm Cath Sngl","41821180","CDM","983","RC","33210","HCPCS","","","facility","both","","","","457.45","457.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 0.5Cm Or <","41821182","CDM","983","RC","11310","HCPCS","","","facility","both","","","","369.53","369.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Image Cath Fluid Peri/Retro","41821183","CDM","983","RC","49406","HCPCS","","","facility","both","","","","2910.71","2910.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Needle Bx Addl","41821184","CDM","983","RC","31633","HCPCS","","","facility","both","","","","230.75","230.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch W/Balloon Occlusion","41821185","CDM","983","RC","31634","HCPCS","","","facility","both","","","","5538.88","5538.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Fb Removal","41821186","CDM","983","RC","31635","HCPCS","","","facility","both","","","","870.25","870.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy W/Tumor Excise","41821187","CDM","983","RC","31640","HCPCS","","","facility","both","","","","684.8","684.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Treat Blockage","41821188","CDM","983","RC","31641","HCPCS","","","facility","both","","","","702.25","702.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Reclear Airway","41821189","CDM","983","RC","31646","HCPCS","","","facility","both","","","","412.26","412.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 0.5Cm/<","41821190","CDM","983","RC","11400","HCPCS","","","facility","both","","","","399.43","399.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Valve Insert Init","41821191","CDM","983","RC","31647","HCPCS","","","facility","both","","","","572.47","572.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Valve Remove Init","41821192","CDM","983","RC","31648","HCPCS","","","facility","both","","","","545.85","545.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Valve Remove Addl","41821193","CDM","983","RC","31649","HCPCS","","","facility","both","","","","184.99","184.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Thermoplasty 1 Lobe","41821194","CDM","983","RC","31660","HCPCS","","","facility","both","","","","541.63","541.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Thermoplsty 2/> Lobes","41821195","CDM","983","RC","31661","HCPCS","","","facility","both","","","","572.09","572.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchial Valve Addl Insert","41821196","CDM","983","RC","31651","HCPCS","","","facility","both","","","","208.71","208.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronch Ebus Intrvnt Perph Les","41821197","CDM","983","RC","31654","HCPCS","","","facility","both","","","","378.47","378.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Photodynmc Tx 30 Min Add-On","41821198","CDM","983","RC","96570","HCPCS","","","facility","both","","","","148.78","148.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Photodynamic Tx Addl 15 Min","41821199","CDM","983","RC","96571","HCPCS","","","facility","both","","","","70.95","70.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","41821200","CDM","983","RC","99497","HCPCS","","","facility","both","","","","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Ea Add 30 Min","41821201","CDM","983","RC","99498","HCPCS","","","facility","both","","","","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Swan Ganz Bedside","41821202","CDM","983","RC","93503","HCPCS","","","facility","both","","","","250.08","250.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Navigational Bronchoscopy Add","41821203","CDM","983","RC","31627","HCPCS","","","facility","both","","","","4278.13","4278.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy/Needle Bx Ea","41821204","CDM","983","RC","31629","HCPCS","","","facility","both","","","","1434.84","1434.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchoscopy Dilate/Fx Repr","41821205","CDM","983","RC","31630","HCPCS","","","facility","both","","","","572.86","572.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Unattended","41821206","CDM","983","RC","95800","HCPCS","","","facility","both","","","26","518.28","518.28","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Sleep Stdy Unattend W/Analysis","41821207","CDM","983","RC","95801","HCPCS","","","facility","both","","","26","270.53","270.53","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Excise Ben Les Trunk 0.6-1.0Cm","41821208","CDM","983","RC","11401","HCPCS","","","facility","both","","","","481.78","481.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Continuous Overnight Oximetry","41821209","CDM","983","RC","94762","HCPCS","","","facility","both","","","","85.95","85.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 1.1-2.0Cm","41821216","CDM","983","RC","11402","HCPCS","","","facility","both","","","","532.64","532.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Trunk 2.1-3C","41821224","CDM","983","RC","11403","HCPCS","","","facility","both","","","","607.49","607.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk >4 Cm","41821232","CDM","983","RC","11406","HCPCS","","","facility","both","","","","963","963","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp <0.5Cm","41821240","CDM","983","RC","11420","HCPCS","","","facility","both","","","","400.36","400.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 0.6-1C","41821257","CDM","983","RC","11421","HCPCS","","","facility","both","","","","498.37","498.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc B9 Les S N Ex G 1.1 2.0Cm","41821265","CDM","983","RC","11422","HCPCS","","","facility","both","","","","558.39","558.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 2.1-3C","41821273","CDM","983","RC","11423","HCPCS","","","facility","both","","","","630.44","630.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Benign Lesion >4.0Cm","41821281","CDM","983","RC","11426","HCPCS","","","facility","both","","","","1015.22","1015.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Lesion Face <0.5Cm","41821299","CDM","983","RC","11440","HCPCS","","","facility","both","","","","444.08","444.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Othr Ben Les 0.6-1.0Cm","41821307","CDM","983","RC","11441","HCPCS","","","facility","both","","","","536.97","536.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 1.1-2Cm","41821315","CDM","983","RC","11442","HCPCS","","","facility","both","","","","593.97","593.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 2.1-3Cm","41821323","CDM","983","RC","11443","HCPCS","","","facility","both","","","","698.13","698.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.5Cm<","41821331","CDM","983","RC","11600","HCPCS","","","facility","both","","","","620.52","620.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.6-1C","41821349","CDM","983","RC","11601","HCPCS","","","facility","both","","","","717.16","717.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 1.1-2C","41821356","CDM","983","RC","11602","HCPCS","","","facility","both","","","","772.74","772.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 2.1-3C","41821364","CDM","983","RC","11603","HCPCS","","","facility","both","","","","873.26","873.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.5Cm<","41821372","CDM","983","RC","11620","HCPCS","","","facility","both","","","","623.17","623.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.6-1C","41821380","CDM","983","RC","11621","HCPCS","","","facility","both","","","","719.79","719.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 1.1-2C","41821398","CDM","983","RC","11622","HCPCS","","","facility","both","","","","795.83","795.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 2.1-3C","41821406","CDM","983","RC","11623","HCPCS","","","facility","both","","","","924.19","924.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 0.5Cm <","41821414","CDM","983","RC","11640","HCPCS","","","facility","both","","","","638.81","638.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Lesion Face 0.6-1Cm","41821422","CDM","983","RC","11641","HCPCS","","","facility","both","","","","744.67","744.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 1.1-2Cm","41821430","CDM","983","RC","11642","HCPCS","","","facility","both","","","","840.36","840.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 2.1-3Cm","41821448","CDM","983","RC","11643","HCPCS","","","facility","both","","","","978.6","978.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smiple Repair Wnd 2.5Cm","41821455","CDM","983","RC","12001","HCPCS","","","facility","both","","","","279.59","279.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Wnd 2.6-7.5 Cm","41821463","CDM","983","RC","12002","HCPCS","","","facility","both","","","","337.51","337.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 7.6-12.5Cm","41821471","CDM","983","RC","12004","HCPCS","","","facility","both","","","","390.91","390.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.5Cm Or <","41821489","CDM","983","RC","12011","HCPCS","","","facility","both","","","","338.49","338.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.6-5Cm","41821497","CDM","983","RC","12013","HCPCS","","","facility","both","","","","349.89","349.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 5.1-7.5Cm","41821505","CDM","983","RC","12014","HCPCS","","","facility","both","","","","423.02","423.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41821513","CDM","983","RC","12031","HCPCS","","","facility","both","","","","795.42","795.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Scalp 2.6-7.5Cm","41821521","CDM","983","RC","12032","HCPCS","","","facility","both","","","","953.47","953.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr S/Tr/Ext 7.6-12.5","41821539","CDM","983","RC","12034","HCPCS","","","facility","both","","","","1011.48","1011.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter N/H/F/G 2.5Cm Or<","41821547","CDM","983","RC","12041","HCPCS","","","facility","both","","","","795.01","795.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 2.6-7.5Cm","41821554","CDM","983","RC","12042","HCPCS","","","facility","both","","","","939.02","939.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 7.6-12.5Cm","41821562","CDM","983","RC","12044","HCPCS","","","facility","both","","","","1165.58","1165.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.5Cm Or <","41821570","CDM","983","RC","12051","HCPCS","","","facility","both","","","","854","854","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.6-5Cm","41821588","CDM","983","RC","12052","HCPCS","","","facility","both","","","","952.18","952.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 5.1-7.5Cm","41821596","CDM","983","RC","12053","HCPCS","","","facility","both","","","","1117.17","1117.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspiration Breast Cyst","41821604","CDM","983","RC","19000","HCPCS","","","facility","both","","","","345.77","345.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspiration Breast Cyst Ea Addl","41821612","CDM","983","RC","19001","HCPCS","","","facility","both","","","","80.77","80.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Breast Needle","41821620","CDM","983","RC","19100","HCPCS","","","facility","both","","","","476.89","476.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Breast Open","41821638","CDM","983","RC","19101","HCPCS","","","facility","both","","","","1027.17","1027.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Throm Hemorrhoid","41821646","CDM","983","RC","46083","HCPCS","","","facility","both","","","","609.04","609.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemorrhoidectomy Simple","41821653","CDM","983","RC","46221","HCPCS","","","facility","both","","","","863.57","863.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy Diagnostic","41821661","CDM","983","RC","46600","HCPCS","","","facility","both","","","","332.9","332.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy W/ Biopsy","41821679","CDM","983","RC","46606","HCPCS","","","facility","both","","","","833.63","833.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Lesion","41821687","CDM","983","RC","46922","HCPCS","","","facility","both","","","","936.17","936.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/L Xtremity Art 2 Levels","41821703","CDM","983","RC","93922","HCPCS","","","facility","both","","","","278.29","278.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/Lxtr Art Stdy 3+ Lvls","41821711","CDM","983","RC","93923","HCPCS","","","facility","both","","","","431.88","431.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","41821745","CDM","983","RC","10061","HCPCS","","","facility","both","","","","638.6","638.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Pilonidal Cyst Simple","41821885","CDM","983","RC","10080","HCPCS","","","facility","both","","","","675.73","675.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna W/O Image","41821901","CDM","983","RC","10021","HCPCS","","","facility","both","","","","303.44","303.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Cplx Postop Wnd Inf","41821927","CDM","983","RC","10180","HCPCS","","","facility","both","","","","787.83","787.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 7.6-12.5Cm","41821950","CDM","983","RC","12015","HCPCS","","","facility","both","","","","508.97","508.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Breast Lesion","41821976","CDM","983","RC","19120","HCPCS","","","facility","both","","","","1508.87","1508.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cauterize Granulation Tissue","41822008","CDM","983","RC","17250","HCPCS","","","facility","both","","","","271.87","271.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","41822024","CDM","983","RC","11042","HCPCS","","","facility","both","","","","396.45","396.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Forearm Lesion Subcut","41822040","CDM","983","RC","25075","HCPCS","","","facility","both","","","","1593.2","1593.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Shoulder Les Sc < 3 Cm","41822065","CDM","983","RC","23075","HCPCS","","","facility","both","","","","1565.94","1565.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Anesthetic Ilioinguinal","41822081","CDM","983","RC","64425","HCPCS","","","facility","both","","","","352.05","352.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Shoulder Lesion","41822107","CDM","983","RC","23076","HCPCS","","","facility","both","","","","1598.3","1598.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr E/N/E/L 10.1-30Sqcm","41822108","CDM","983","RC","14061","HCPCS","","","facility","both","","","","2932.35","2932.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Marsup Cyst Barth's Gland","41822125","CDM","983","RC","56440","HCPCS","","","facility","both","","","","532.64","532.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Audiometry Puretone Screen","41822126","CDM","983","RC","92551","HCPCS","","","facility","both","","","","44.27","44.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ob Us Nuchal Meas 1 Gest","41822127","CDM","983","RC","76813","HCPCS","","","facility","both","","","","379.5","379.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Emg Anal/Urethral Sphincter","41822132","CDM","983","RC","51784","HCPCS","","","facility","both","","","","207.1","207.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy Cervix W Endocervic","41822134","CDM","983","RC","57456","HCPCS","","","facility","both","","","","439.06","439.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41822137","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Episiotomy Vaginal Rpr","41822139","CDM","983","RC","59300","HCPCS","","","facility","both","","","","637.29","637.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove W Ins Drug Implant","41822140","CDM","983","RC","11983","HCPCS","","","facility","both","","","","433.25","433.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Mastotomy Expl/Drain Abs","41822141","CDM","983","RC","19020","HCPCS","","","facility","both","","","","1473.78","1473.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Mastotomy Expl/Drain Abs","41822142","CDM","983","RC","19020","HCPCS","","","facility","both","","","","1473.78","1473.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Drug Implant","41822150","CDM","983","RC","11981","HCPCS","","","facility","both","","","","313.64","313.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comb Ant Post Colporrhaphy W","41822153","CDM","983","RC","57265","HCPCS","","","facility","both","","","","2526.52","2526.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route 1St","41822159","CDM","983","RC","90460","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Immun Admin Any Route Ea Ad","41822161","CDM","983","RC","90461","HCPCS","","","facility","both","","","","39.14","39.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Global","41822189","CDM","983","RC","93000","HCPCS","","","facility","both","","","","52.32","52.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 5-10 Min","41822200","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 11-20 Min","41822201","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone E/M Phys/Qhp 21-30 Min","41822202","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occular Instrumnt Screen Bil","41822203","CDM","983","RC","99174","HCPCS","","","facility","both","","","","107.57","107.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystourethroscopy","41822204","CDM","983","RC","52000","HCPCS","","","facility","both","","","","670.15","670.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Adbomen","41822205","CDM","983","RC","49402","HCPCS","","","facility","both","","","","2448.88","2448.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","41822206","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hydration Iv Infusion Init","41822208","CDM","983","RC","96360","HCPCS","","","facility","both","","","","109.59","109.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Nutrician Therapy Ea 15Mi","41822209","CDM","983","RC","97802","HCPCS","","","facility","both","","","","114.15","114.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41822210","CDM","983","RC","G0108","HCPCS","","","facility","both","","","","166.42","166.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Grp","41822211","CDM","983","RC","G0109","HCPCS","","","facility","both","","","","46.66","46.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Blood","41822349","CDM","300","RC","82270","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 18-39 Yrs","41822507","CDM","983","RC","99385","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 40-64 Yrs","41822515","CDM","983","RC","99386","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt Over 65 Yrs","41822523","CDM","983","RC","99387","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 18-39 Yrs","41822531","CDM","983","RC","99395","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 40-64 Yrs","41822549","CDM","983","RC","99396","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 65>","41822557","CDM","983","RC","99397","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy/Excise Of Lesion Cervix","41822565","CDM","983","RC","57500","HCPCS","","","facility","both","","","","451.84","451.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vaginal","41822573","CDM","983","RC","57100","HCPCS","","","facility","both","","","","291.49","291.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Vulvar","41822581","CDM","983","RC","56605","HCPCS","","","facility","both","","","","274.44","274.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Bladder Catheter","41822599","CDM","983","RC","51701","HCPCS","","","facility","both","","","","136.61","136.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Temp Bladder Cath","41822607","CDM","983","RC","51702","HCPCS","","","facility","both","","","","192.97","192.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cautery Of Cervux","41822615","CDM","983","RC","57510","HCPCS","","","facility","both","","","","455.65","455.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy Of Cervix","41822623","CDM","983","RC","57452","HCPCS","","","facility","both","","","","363.26","363.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx/Curett Of Cervix W/ Scope","41822631","CDM","983","RC","57454","HCPCS","","","facility","both","","","","487.04","487.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endocervical Curettage","41822649","CDM","983","RC","57505","HCPCS","","","facility","both","","","","402.66","402.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endometrial Biopsy","41822657","CDM","983","RC","58100","HCPCS","","","facility","both","","","","295.33","295.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryosurgery Cervix","41822665","CDM","983","RC","57511","HCPCS","","","facility","both","","","","533.82","533.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Condyloma","41822673","CDM","983","RC","56515","HCPCS","","","facility","both","","","","766.66","766.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Vaginal Lesion","41822681","CDM","983","RC","57061","HCPCS","","","facility","both","","","","441.15","441.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Vulva Les Any Method","41822699","CDM","983","RC","56501","HCPCS","","","facility","both","","","","509.57","509.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diaphragm Fitting","41822707","CDM","983","RC","57170","HCPCS","","","facility","both","","","","212.83","212.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Bartholins Gland Abscess","41822715","CDM","983","RC","56420","HCPCS","","","facility","both","","","","485.44","485.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wet Mount","41822723","CDM","300","RC","87210","HCPCS","","","facility","both","","","QW","13","13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"I D Vulva Perineal Abscess","41822731","CDM","983","RC","56405","HCPCS","","","facility","both","","","","390.63","390.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Cervical Dilator","41822749","CDM","983","RC","59200","HCPCS","","","facility","both","","","","273.79","273.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Iud","41822757","CDM","983","RC","58300","HCPCS","","","facility","both","","","","239.1","239.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Iud","41822765","CDM","983","RC","58301","HCPCS","","","facility","both","","","","307.22","307.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy W/ Loope Electrode","41822773","CDM","983","RC","57460","HCPCS","","","facility","both","","","","957.26","957.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Norplant Removal","41822799","CDM","983","RC","11976","HCPCS","","","facility","both","","","","438.11","438.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stress Test Non-Fetal (Hosp)","41822807","CDM","983","RC","59025","HCPCS","","","facility","both","","","26","143.76","143.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Pessary Insertion","41822815","CDM","983","RC","57160","HCPCS","","","facility","both","","","","206.07","206.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vaginal Foreign Body","41822823","CDM","983","RC","57415","HCPCS","","","facility","both","","","","505.24","505.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct B9 Lesion 1-14","41822831","CDM","983","RC","17110","HCPCS","","","facility","both","","","","358","358","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua Wo Micro","41822857","CDM","300","RC","81002","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pregnancy Test","41822865","CDM","300","RC","81025","HCPCS","","","facility","both","","","","24","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Fingerstick","41822873","CDM","300","RC","82962","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41822900","CDM","983","RC","90471","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41822908","CDM","983","RC","90472","HCPCS","","","facility","both","","","","39.14","39.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iud Paragard","41822923","CDM","250","RC","J7300","HCPCS","","","facility","both","","","","1009.4","1009.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antepartum Care 4-6 Visits","41822965","CDM","983","RC","59425","HCPCS","","","facility","both","","","","1366.81","1366.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antepartum Care 7 Or More Vis","41822973","CDM","983","RC","59426","HCPCS","","","facility","both","","","","2440.38","2440.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Postpartum Care","41822981","CDM","983","RC","59430","HCPCS","","","facility","both","","","","614.89","614.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Cplx Postop Wnd Inf","41823207","CDM","983","RC","10180","HCPCS","","","facility","both","","","","787.83","787.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspiration Breast Cyst","41823215","CDM","983","RC","19000","HCPCS","","","facility","both","","","","345.77","345.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41823231","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41823249","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41823257","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41823265","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41823273","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41823281","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41823307","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41823331","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41823349","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41823357","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41823365","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"I And D Vag Hematoma Nonob","41823381","CDM","983","RC","57023","HCPCS","","","facility","both","","","","927.26","927.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"I And D Vaginal Hematoma Pp","41823407","CDM","983","RC","57022","HCPCS","","","facility","both","","","","520.22","520.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryosurgery Anal Lesion(S)","41823423","CDM","983","RC","46916","HCPCS","","","facility","both","","","","782.88","782.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy Entire Vag","41823449","CDM","983","RC","57420","HCPCS","","","facility","both","","","","378.83","378.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exam/Bx Of Vag W/ Scope","41823465","CDM","983","RC","57421","HCPCS","","","facility","both","","","","509.08","509.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Skin Tags 15 Lesions","41823481","CDM","983","RC","11200","HCPCS","","","facility","both","","","","277.28","277.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex Cystometrogram","41823507","CDM","983","RC","51726","HCPCS","","","facility","both","","","","935.93","935.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intra-Abdominal Pressure Test","41823549","CDM","983","RC","51797","HCPCS","","","facility","both","","","","527.77","527.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex Uroflowmetry","41823581","CDM","983","RC","51741","HCPCS","","","facility","both","","","","43.24","43.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simple Uroflowmetry","41823607","CDM","983","RC","51736","HCPCS","","","facility","both","","","","41.59","41.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Vulva/Pr Ea Addl Les","41823631","CDM","983","RC","56606","HCPCS","","","facility","both","","","","114.56","114.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obtaining Screen Pap","41823657","CDM","983","RC","Q0091","HCPCS","","","facility","both","","","","134.6","134.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Absc Smpl Or Sgl","41823673","CDM","983","RC","10060","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"N Block Inj, Paracervical","41823699","CDM","983","RC","64435","HCPCS","","","facility","both","","","","225.93","225.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hysteroscopy Biopsy","41823715","CDM","983","RC","58558","HCPCS","","","facility","both","","","","4593.56","4593.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ca Scn Pelvic/Breast Exam","41823731","CDM","983","RC","G0101","HCPCS","","","facility","both","","","","119.71","119.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Visit - 16 Weeks","41823749","CDM","983","RC","Z1032","HCPCS","","","facility","both","","","ZL","832.55","832.55","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier ZL: Used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. Reimbursable only once during a pregnancy."
"Initial Pregnancy Office Visit","41823757","CDM","983","RC","Z1032","HCPCS","","","facility","both","","","","484.09","484.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antepartum Ov 2-13 Visits","41823765","CDM","983","RC","Z1034","HCPCS","","","facility","both","","","","231.52","231.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Postpartum Ov","41823781","CDM","983","RC","Z1038","HCPCS","","","facility","both","","","","231.52","231.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 12-17 Yrs","41823849","CDM","983","RC","99394","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Comfor Knee Immobilizer Univ24","41823873","CDM","271","RC","","","","","facility","both","","","","59.65","59.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cath Tray Urimeter","41823899","CDM","272","RC","","","","","facility","both","","","","192.67","192.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shields Brace","41823915","CDM","271","RC","","","","","facility","both","","","","192.97","192.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patella Stabilizer Hinged","41823923","CDM","271","RC","","","","","facility","both","","","","72.14","72.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Patella Stabilizer W/ Condylar","41823931","CDM","271","RC","L1820","HCPCS","","","facility","both","","","","115.72","115.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Latex Free Volley Tennis Elbow","41823999","CDM","270","RC","","","","","facility","both","","","","64.38","64.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/ Micro","41824057","CDM","300","RC","81000","HCPCS","","","facility","both","","","","11","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spun Hematocrit","41824065","CDM","300","RC","85013","HCPCS","","","facility","both","","","","20","20","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ppd","41824073","CDM","300","RC","86580","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strep Screen","41824081","CDM","300","RC","87880","HCPCS","","","facility","both","","","QW","38","38","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Spirometry","41824099","CDM","460","RC","94010","HCPCS","","","facility","both","","","","103","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry Pre And Post","41824107","CDM","460","RC","94060","HCPCS","","","facility","both","","","","172","172","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg - Technical Fee","41825557","CDM","730","RC","93005","HCPCS","","","facility","both","","","","31","31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Ca Screening Dre","41825565","CDM","983","RC","G0102","HCPCS","","","facility","both","","","","72.15","72.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","41825607","CDM","983","RC","10061","HCPCS","","","facility","both","","","","638.6","638.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Simple","41825615","CDM","983","RC","10120","HCPCS","","","facility","both","","","","479.72","479.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Benign Lesion >4.0Cm","41825631","CDM","983","RC","11426","HCPCS","","","facility","both","","","","1015.22","1015.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","41825649","CDM","983","RC","10140","HCPCS","","","facility","both","","","","530.14","530.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","41825657","CDM","983","RC","10160","HCPCS","","","facility","both","","","","406.03","406.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Ext Eczema/Infect Skin","41825665","CDM","983","RC","11000","HCPCS","","","facility","both","","","","175.41","175.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem Add 20 Cm/<","41825673","CDM","983","RC","97598","HCPCS","","","facility","both","","","","141.66","141.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion Single","41825681","CDM","983","RC","11055","HCPCS","","","facility","both","","","","203.01","203.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion 2-4","41825699","CDM","983","RC","11056","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Tags Ea Add'l 10","41825723","CDM","983","RC","11201","HCPCS","","","facility","both","","","","55.11","55.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk 0.5Cm Or <","41825731","CDM","983","RC","11300","HCPCS","","","facility","both","","","","322.15","322.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 0.6-1Cm","41825749","CDM","983","RC","11301","HCPCS","","","facility","both","","","","386.58","386.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 1.1-2Cm","41825757","CDM","983","RC","11302","HCPCS","","","facility","both","","","","446.48","446.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk > 2.0 Cm","41825765","CDM","983","RC","11303","HCPCS","","","facility","both","","","","489.38","489.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck <0.5Cm","41825773","CDM","983","RC","11305","HCPCS","","","facility","both","","","","334.49","334.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Scalp/Neck .6-1Cm","41825781","CDM","983","RC","11306","HCPCS","","","facility","both","","","","391.33","391.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 0.5Cm Or <","41825799","CDM","983","RC","11310","HCPCS","","","facility","both","","","","369.53","369.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Face 0.6-1.0 Cm","41825807","CDM","983","RC","11311","HCPCS","","","facility","both","","","","434.71","434.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Face 1.1-2.0 Cm","41825815","CDM","983","RC","11312","HCPCS","","","facility","both","","","","501.94","501.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Tr-Ext B9+Marg 0.5Cm/<","41825823","CDM","983","RC","11400","HCPCS","","","facility","both","","","","399.43","399.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 0.6-1.0Cm","41825831","CDM","983","RC","11401","HCPCS","","","facility","both","","","","481.78","481.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk 1.1-2.0Cm","41825849","CDM","983","RC","11402","HCPCS","","","facility","both","","","","532.64","532.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Trunk 2.1-3C","41825857","CDM","983","RC","11403","HCPCS","","","facility","both","","","","607.49","607.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ben Les Trunk 3.1-4.0 Cm","41825865","CDM","983","RC","11404","HCPCS","","","facility","both","","","","687.5","687.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Les Trunk >4 Cm","41825873","CDM","983","RC","11406","HCPCS","","","facility","both","","","","963","963","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp <0.5Cm","41825881","CDM","983","RC","11420","HCPCS","","","facility","both","","","","400.36","400.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 0.6-1C","41825899","CDM","983","RC","11421","HCPCS","","","facility","both","","","","498.37","498.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc B9 Les S N Ex G  1.1-2.0Cm","41825907","CDM","983","RC","11422","HCPCS","","","facility","both","","","","558.39","558.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp 2.1-3C","41825915","CDM","983","RC","11423","HCPCS","","","facility","both","","","","630.44","630.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Lesion Face <0.5Cm","41825923","CDM","983","RC","11440","HCPCS","","","facility","both","","","","444.08","444.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion 1St","41825931","CDM","983","RC","17000","HCPCS","","","facility","both","","","","203.84","203.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Othr Ben Les 0.6-1.0Cm","41825949","CDM","983","RC","11441","HCPCS","","","facility","both","","","","536.97","536.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 1.1-2Cm","41825957","CDM","983","RC","11442","HCPCS","","","facility","both","","","","593.97","593.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Face 2.1-3Cm","41825965","CDM","983","RC","11443","HCPCS","","","facility","both","","","","698.13","698.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.5Cm<","41825973","CDM","983","RC","11600","HCPCS","","","facility","both","","","","620.52","620.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 0.6-1C","41825981","CDM","983","RC","11601","HCPCS","","","facility","both","","","","717.16","717.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 1.1-2C","41825999","CDM","983","RC","11602","HCPCS","","","facility","both","","","","772.74","772.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 2.1-3C","41826007","CDM","983","RC","11603","HCPCS","","","facility","both","","","","873.26","873.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk >4.0Cm","41826015","CDM","983","RC","11606","HCPCS","","","facility","both","","","","1367.5","1367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.5Cm<","41826023","CDM","983","RC","11620","HCPCS","","","facility","both","","","","623.17","623.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 0.6-1C","41826031","CDM","983","RC","11621","HCPCS","","","facility","both","","","","719.79","719.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 1.1-2C","41826049","CDM","983","RC","11622","HCPCS","","","facility","both","","","","795.83","795.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Scalp 2.1-3C","41826057","CDM","983","RC","11623","HCPCS","","","facility","both","","","","924.19","924.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 0.5Cm <","41826065","CDM","983","RC","11640","HCPCS","","","facility","both","","","","638.81","638.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Lesion Face 0.6-1Cm","41826073","CDM","983","RC","11641","HCPCS","","","facility","both","","","","744.67","744.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 1.1-2Cm","41826081","CDM","983","RC","11642","HCPCS","","","facility","both","","","","840.36","840.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Face 2.1-3Cm","41826099","CDM","983","RC","11643","HCPCS","","","facility","both","","","","978.6","978.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails 1-5","41826107","CDM","983","RC","11720","HCPCS","","","facility","both","","","","102.2","102.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails >6","41826115","CDM","983","RC","11721","HCPCS","","","facility","both","","","","139.18","139.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simpl Avulsion Nail Plt Single","41826123","CDM","983","RC","11730","HCPCS","","","facility","both","","","","346.54","346.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avulsion Nail Ea 2+","41826131","CDM","983","RC","11732","HCPCS","","","facility","both","","","","103.36","103.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Evacuate Subungual Hematoma","41826149","CDM","983","RC","11740","HCPCS","","","facility","both","","","","171.57","171.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Nail/Matrix Perm Remove","41826157","CDM","983","RC","11750","HCPCS","","","facility","both","","","","489.79","489.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Intralesional >7","41826165","CDM","983","RC","11901","HCPCS","","","facility","both","","","","212.06","212.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smiple Repair Wnd 2.5Cm","41826173","CDM","983","RC","12001","HCPCS","","","facility","both","","","","279.59","279.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Wnd 2.6-7.5 Cm","41826181","CDM","983","RC","12002","HCPCS","","","facility","both","","","","337.51","337.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 7.6-12.5Cm","41826199","CDM","983","RC","12004","HCPCS","","","facility","both","","","","390.91","390.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Scalp 12.6-20Cm","41826207","CDM","983","RC","12005","HCPCS","","","facility","both","","","","513.95","513.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.5Cm Or <","41826215","CDM","983","RC","12011","HCPCS","","","facility","both","","","","338.49","338.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.6-5Cm","41826223","CDM","983","RC","12013","HCPCS","","","facility","both","","","","349.89","349.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 5.1-7.5Cm","41826231","CDM","983","RC","12014","HCPCS","","","facility","both","","","","423.02","423.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41826249","CDM","983","RC","12031","HCPCS","","","facility","both","","","","795.42","795.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Scalp 2.6-7.5Cm","41826257","CDM","983","RC","12032","HCPCS","","","facility","both","","","","953.47","953.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr S/Tr/Ext 7.6-12.5","41826265","CDM","983","RC","12034","HCPCS","","","facility","both","","","","1011.48","1011.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter N/H/F/G 2.5Cm Or<","41826273","CDM","983","RC","12041","HCPCS","","","facility","both","","","","795.01","795.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 2.6-7.5Cm","41826281","CDM","983","RC","12042","HCPCS","","","facility","both","","","","939.02","939.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Neck 7.6-12.5Cm","41826299","CDM","983","RC","12044","HCPCS","","","facility","both","","","","1165.58","1165.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.5Cm Or <","41826307","CDM","983","RC","12051","HCPCS","","","facility","both","","","","854","854","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 2.6-5Cm","41826315","CDM","983","RC","12052","HCPCS","","","facility","both","","","","952.18","952.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Inter Face 5.1-7.5Cm","41826323","CDM","983","RC","12053","HCPCS","","","facility","both","","","","1117.17","1117.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Complex S A L 1.1-2.5Cm","41826331","CDM","983","RC","13120","HCPCS","","","facility","both","","","","1115.78","1115.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Brn Sm","41826349","CDM","983","RC","16020","HCPCS","","","facility","both","","","","257.76","257.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debride Burn, Large","41826357","CDM","983","RC","16030","HCPCS","","","facility","both","","","","591.17","591.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruct Skin Lesion Ea 2-14","41826365","CDM","983","RC","17003","HCPCS","","","facility","both","","","","19.47","19.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion >15","41826381","CDM","983","RC","17004","HCPCS","","","facility","both","","","","497.68","497.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Flat Warts >15","41826399","CDM","983","RC","17111","HCPCS","","","facility","both","","","","417.39","417.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chemical Cautery, Tissue","41826407","CDM","983","RC","17250","HCPCS","","","facility","both","","","","271.87","271.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Breast Lesion","41826415","CDM","983","RC","19120","HCPCS","","","facility","both","","","","1508.87","1508.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tendon Sheath","41826423","CDM","983","RC","20550","HCPCS","","","facility","both","","","","164.16","164.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1-2 Muscles","41826431","CDM","983","RC","20552","HCPCS","","","facility","both","","","","169.57","169.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Trigger Points 3/>","41826449","CDM","983","RC","20553","HCPCS","","","facility","both","","","","195.19","195.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrocentesis Small Joint","41826457","CDM","983","RC","20600","HCPCS","","","facility","both","","","","151.67","151.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Joint/Bursa W/O Us","41826465","CDM","983","RC","20605","HCPCS","","","facility","both","","","","157.23","157.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain/Inj Major Joint W/O Us","41826473","CDM","983","RC","20610","HCPCS","","","facility","both","","","","186.17","186.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate/Inj Ganglion Cyste","41826481","CDM","983","RC","20612","HCPCS","","","facility","both","","","","189.04","189.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Humrl Shft Fx Wo Mnp","41826499","CDM","983","RC","24500","HCPCS","","","facility","both","","","","1109.62","1109.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Elbow Dislc W/O Anes","41826507","CDM","983","RC","24600","HCPCS","","","facility","both","","","","1119.84","1119.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Nursemaid Elbow","41826515","CDM","983","RC","24640","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Dstl Rdl Fx Wo Mnp","41826523","CDM","983","RC","25600","HCPCS","","","facility","both","","","","1039.48","1039.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cltx Carp/Metacarp Dis","41826531","CDM","983","RC","26670","HCPCS","","","facility","both","","","","1046.48","1046.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Leg Ankle Deep Absc Hema","41826549","CDM","983","RC","27603","HCPCS","","","facility","both","","","","1650.61","1650.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Arm","41826557","CDM","983","RC","29065","HCPCS","","","facility","both","","","","292.54","292.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Arm","41826565","CDM","983","RC","29075","HCPCS","","","facility","both","","","","264.61","264.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Gauntlet","41826573","CDM","983","RC","29085","HCPCS","","","facility","both","","","","290.9","290.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Arm","41826581","CDM","983","RC","29105","HCPCS","","","facility","both","","","","249.67","249.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Arm","41826599","CDM","983","RC","29125","HCPCS","","","facility","both","","","","200.28","200.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Finger","41826607","CDM","983","RC","29130","HCPCS","","","facility","both","","","","123.94","123.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Long Leg","41826615","CDM","983","RC","29345","HCPCS","","","facility","both","","","","410.82","410.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cast Short Leg","41826623","CDM","983","RC","29405","HCPCS","","","facility","both","","","","244.44","244.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Long Leg","41826631","CDM","983","RC","29505","HCPCS","","","facility","both","","","","265.33","265.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Leg","41826649","CDM","983","RC","29515","HCPCS","","","facility","both","","","","216.78","216.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Paste/Unna Boot","41826657","CDM","983","RC","29580","HCPCS","","","facility","both","","","","197.64","197.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Gauntlet,Boot,Body Cast","41826665","CDM","983","RC","29700","HCPCS","","","facility","both","","","","194.08","194.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Control Nasal Hemorrhage Simpl","41826673","CDM","983","RC","30901","HCPCS","","","facility","both","","","","452.22","452.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/O Imaging","41826683","CDM","983","RC","32554","HCPCS","","","facility","both","","","","704.03","704.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","41826684","CDM","983","RC","32555","HCPCS","","","facility","both","","","","995.5","995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Throm Hemorrhoid","41826699","CDM","983","RC","46083","HCPCS","","","facility","both","","","","609.04","609.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Hemorrhoid Clot","41826707","CDM","983","RC","46320","HCPCS","","","facility","both","","","","619.94","619.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy Diagnostic","41826715","CDM","983","RC","46600","HCPCS","","","facility","both","","","","332.9","332.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Anal Lesion","41826723","CDM","983","RC","46922","HCPCS","","","facility","both","","","","936.17","936.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Les Penis Cryosurgery","41826749","CDM","983","RC","54056","HCPCS","","","facility","both","","","","440.84","440.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision, Clamp Newborn","41826765","CDM","983","RC","54150","HCPCS","","","facility","both","","","","467.69","467.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Circumcision Other Than Clamp","41826773","CDM","983","RC","54160","HCPCS","","","facility","both","","","","678.1","678.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Done W/ Colposcopy Addon","41826781","CDM","983","RC","58110","HCPCS","","","facility","both","","","","149.61","149.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","41826799","CDM","983","RC","62270","HCPCS","","","facility","both","","","","436.93","436.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb Ext Eye Conjunctiva","41826807","CDM","983","RC","65205","HCPCS","","","facility","both","","","","114.98","114.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Fb External Ear","41826815","CDM","983","RC","69200","HCPCS","","","facility","both","","","","251.76","251.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Impact Ear Wax W/Instr Uni","41826823","CDM","983","RC","69210","HCPCS","","","facility","both","","","","143.14","143.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us 3D Ren W/Interp W/O Ind","41826824","CDM","983","RC","76376","HCPCS","","","facility","both","","","","72","72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us < 14 Wks Single Fetus","41826825","CDM","983","RC","76801","HCPCS","","","facility","both","","","","386.97","386.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us 1St Trimester Ea Addtl Fetu","41826826","CDM","983","RC","76802","HCPCS","","","facility","both","","","","193.2","193.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us > 14 Weeks","41826827","CDM","983","RC","76805","HCPCS","","","facility","both","","","","446.64","446.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us > 14 Weeks Addtl Fetus","41826828","CDM","983","RC","76810","HCPCS","","","facility","both","","","","284.56","284.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Detailed","41826829","CDM","983","RC","76811","HCPCS","","","facility","both","","","","553.01","553.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Detailed Addtl Fetus","41826830","CDM","983","RC","76812","HCPCS","","","facility","both","","","","627.06","627.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tympanometry","41826831","CDM","983","RC","92567","HCPCS","","","facility","both","","","","48.87","48.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us Limited 1+ Fetus(S)","41826832","CDM","983","RC","76815","HCPCS","","","facility","both","","","","266.53","266.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Followup","41826833","CDM","983","RC","76816","HCPCS","","","facility","both","","","","360.29","360.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Transvaginal","41826834","CDM","983","RC","76817","HCPCS","","","facility","both","","","","303.87","303.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Fetal Bio Profile W/O Nst","41826835","CDM","983","RC","76819","HCPCS","","","facility","both","","","","273.62","273.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Doppler Fetal Umbilical Art","41826836","CDM","983","RC","76820","HCPCS","","","facility","both","","","","145.04","145.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Doppler Middler Cerebral Ar","41826837","CDM","983","RC","76821","HCPCS","","","facility","both","","","","287.73","287.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Echo Fetal Initial","41826838","CDM","983","RC","76825","HCPCS","","","facility","both","","","","880.6","880.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Echo Fetal Followup","41826839","CDM","983","RC","76826","HCPCS","","","facility","both","","","","525.79","525.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Doppler Initial","41826840","CDM","983","RC","76827","HCPCS","","","facility","both","","","","232.91","232.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Doppler Followup","41826841","CDM","983","RC","76828","HCPCS","","","facility","both","","","","161.74","161.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Gyn Transvag","41826842","CDM","983","RC","76830","HCPCS","","","facility","both","","","","396.96","396.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Gyn Trans Abd","41826843","CDM","983","RC","76856","HCPCS","","","facility","both","","","","351.62","351.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/L Xtremity Art 2 Levels","41826849","CDM","983","RC","93922","HCPCS","","","facility","both","","","","278.29","278.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nebulizer","41826873","CDM","983","RC","94640","HCPCS","","","facility","both","","","","58.92","58.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 1-2 Body Regions","41826881","CDM","983","RC","98925","HCPCS","","","facility","both","","","","94.58","94.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 3-4 Body Regions","41826899","CDM","983","RC","98926","HCPCS","","","facility","both","","","","135.7","135.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 5-6 Body Regions","41826907","CDM","983","RC","98927","HCPCS","","","facility","both","","","","177.13","177.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 7-8 Body Regions","41826915","CDM","983","RC","98928","HCPCS","","","facility","both","","","","215.42","215.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Omt 9-10 Body Regions","41826923","CDM","983","RC","98929","HCPCS","","","facility","both","","","","255.83","255.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sports/School Physical","41826949","CDM","983","RC","99499","HCPCS","","","facility","both","","","","36.05","36.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drivers Physical","41826957","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Employment Physical","41826965","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt Under 1 Yre","41826999","CDM","983","RC","99381","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 1-4 Yrs","41827007","CDM","983","RC","99382","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 5-11 Yrse","41827015","CDM","983","RC","99383","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive New Pt 12-17 Yrs","41827023","CDM","983","RC","99384","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt Under 1 Yr","41827031","CDM","983","RC","99391","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 1-4 Yrs","41827049","CDM","983","RC","99392","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Estab Pt 5-11 Yrs","41827057","CDM","983","RC","99393","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","41827065","CDM","983","RC","99406","HCPCS","","","facility","both","","","","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","41827073","CDM","983","RC","99407","HCPCS","","","facility","both","","","","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Report","41827081","CDM","983","RC","","","","","facility","both","","","","28.77","28.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Preventive Exam","41827107","CDM","983","RC","G0402","HCPCS","","","facility","both","","","","497.93","497.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41827115","CDM","983","RC","G0403","HCPCS","","","facility","both","","","","52.32","52.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ekg Interpret And Report Ippe","41827123","CDM","983","RC","G0405","HCPCS","","","facility","both","","","","24.41","24.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Int Rep","41827131","CDM","983","RC","93010","HCPCS","","","facility","both","","","","24.41","24.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystometrogram W/ Up","41827443","CDM","983","RC","51727","HCPCS","","","facility","both","","","","1118.71","1118.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystometrogram W/ Vp","41827451","CDM","983","RC","51728","HCPCS","","","facility","both","","","","1135.24","1135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystometrogram W/ Up And Vp","41827469","CDM","983","RC","51729","HCPCS","","","facility","both","","","","1201.86","1201.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41827477","CDM","942","RC","G0108","HCPCS","","","facility","both","","","","183","183","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reassess Nutrition Ther Ea 15M","41827501","CDM","983","RC","97803","HCPCS","","","facility","both","","","","99.09","99.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt, Group, Each 30 Minutes","41827519","CDM","942","RC","97804","HCPCS","","","facility","both","","","","46","46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Vag Graft Via Vagina","41827527","CDM","983","RC","57295","HCPCS","","","facility","both","","","","1454.59","1454.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Cervix W/ Scope","41827577","CDM","983","RC","57455","HCPCS","","","facility","both","","","","466.21","466.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Mal Sk Les Trunk 3.1-4C","41827635","CDM","983","RC","11604","HCPCS","","","facility","both","","","","970.41","970.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rpr Lac Cplx Forehd 1-2.5Cm","41827669","CDM","983","RC","13131","HCPCS","","","facility","both","","","","1217.59","1217.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Appl Cast Leg Short Walk","41827685","CDM","983","RC","29425","HCPCS","","","facility","both","","","","234.46","234.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Initial Visit","41827693","CDM","983","RC","G0438","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ppps, Subseq Visit","41827701","CDM","983","RC","G0439","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","41827727","CDM","983","RC","97597","HCPCS","","","facility","both","","","","306.75","306.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bladder Irrigation Simple","41827743","CDM","983","RC","51700","HCPCS","","","facility","both","","","","236.44","236.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Bl W/Cath Insertion","41828027","CDM","983","RC","51102","HCPCS","","","facility","both","","","","731.61","731.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bladder Irrigation Simple","41828043","CDM","983","RC","51700","HCPCS","","","facility","both","","","","236.44","236.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Insert Bladder Catheter","41828069","CDM","983","RC","51701","HCPCS","","","facility","both","","","","136.61","136.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Insert Temp Bladder Cath","41828085","CDM","983","RC","51702","HCPCS","","","facility","both","","","","192.97","192.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Of Bladder Tube","41828101","CDM","983","RC","51705","HCPCS","","","facility","both","","","","296.83","296.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Of Bladder Lesion","41828127","CDM","983","RC","51720","HCPCS","","","facility","both","","","","259.53","259.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Complex Cystometrogram","41828143","CDM","983","RC","51726","HCPCS","","","facility","both","","","","935.93","935.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Electro-Uroflowmetry First","41828169","CDM","983","RC","51741","HCPCS","","","facility","both","","","","43.24","43.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Anal/Urinary Muscle Study","41828185","CDM","983","RC","51784","HCPCS","","","facility","both","","","","207.1","207.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Spine Fusion Anterior","41828186","CDM","983","RC","22558","HCPCS","","","facility","both","","","","4295.03","4295.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Waterjet Prostate Ablat Complt","41828187","CDM","983","RC","0421T","HCPCS","","","facility","both","","","","257.5","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Intraabdominal Pressure Tes","41828201","CDM","983","RC","51797","HCPCS","","","facility","both","","","","527.77","527.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pv Residual Urine","41828227","CDM","983","RC","51798","HCPCS","","","facility","both","","","","33.87","33.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystoscopy","41828243","CDM","983","RC","52000","HCPCS","","","facility","both","","","","670.15","670.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystoscopy W/Biopsy(S)","41828269","CDM","983","RC","52204","HCPCS","","","facility","both","","","","1233.79","1233.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystoscopy And Treatment","41828285","CDM","983","RC","52310","HCPCS","","","facility","both","","","","904.47","904.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Circum 28 Days Or Older","41828301","CDM","983","RC","54161","HCPCS","","","facility","both","","","","581.05","581.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Removal Of Sperm Duct(S)","41828327","CDM","983","RC","55250","HCPCS","","","facility","both","","","","1133.65","1133.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Biopsy Of Prostate","41828343","CDM","983","RC","55700","HCPCS","","","facility","both","","","","774.18","774.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Pudendal Nerve","41828369","CDM","983","RC","64430","HCPCS","","","facility","both","","","","278.08","278.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Us Exam Pelvic Limited","41828385","CDM","983","RC","76857","HCPCS","","","facility","both","","","","151.03","151.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Us Transrectal","41828401","CDM","983","RC","76872","HCPCS","","","facility","both","","","","468.08","468.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Needle Placement","41828427","CDM","983","RC","76942","HCPCS","","","facility","both","","","26","176.65","176.65","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Urinalysis Nonauto W/Scope","41828435","CDM","300","RC","81000","HCPCS","","","facility","both","","","","11","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41828438","CDM","983","RC","90471","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41828440","CDM","983","RC","90472","HCPCS","","","facility","both","","","","39.14","39.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Ca Screening Dre","41828443","CDM","983","RC","G0102","HCPCS","","","facility","both","","","","72.15","72.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Prostatic Rf Thermotx","41828469","CDM","983","RC","53852","HCPCS","","","facility","both","","","","4960.58","4960.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Circumcision W/Regionl Bloc","41828485","CDM","983","RC","54150","HCPCS","","","facility","both","","","","467.69","467.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystometrogram W/Up","41828501","CDM","983","RC","51727","HCPCS","","","facility","both","","","","1118.71","1118.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystometrogram W/Vp","41828527","CDM","983","RC","51728","HCPCS","","","facility","both","","","","1135.24","1135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cystometrogram W Vp Up","41828543","CDM","983","RC","51729","HCPCS","","","facility","both","","","","1201.86","1201.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41828627","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41828643","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hysteroscopy W Rem Impacted F","41828802","CDM","983","RC","58562","HCPCS","","","facility","both","","","","1221.92","1221.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ext Cephalic Version","41828803","CDM","983","RC","59412","HCPCS","","","facility","both","","","","287.58","287.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Neuroeltrd Stim Post Tibial","41828835","CDM","983","RC","64566","HCPCS","","","facility","both","","","","409.43","409.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Mark Thor For Rad Perq","41828836","CDM","983","RC","32553","HCPCS","","","facility","both","","","","1705.45","1705.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peel, Non Acid","41828839","CDM","983","RC","","","","","facility","both","","","","280.63","280.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perc Fix Sc/Tc Humerus Fx","41828848","CDM","983","RC","24538","HCPCS","","","facility","both","","","","2283.22","2283.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Synovectomy Tendon Shth Radica","41828849","CDM","983","RC","26145","HCPCS","","","facility","both","","","","1548.04","1548.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extensor Tendon Repair Each","41828850","CDM","983","RC","26418","HCPCS","","","facility","both","","","","1880.78","1880.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Dx Abdomen Peritoneum","41828851","CDM","983","RC","49320","HCPCS","","","facility","both","","","","949.06","949.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Abd Perit Omentum W Bx","41828852","CDM","983","RC","49321","HCPCS","","","facility","both","","","","997.25","997.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Abd Perit Omentum Asp Cyst","41828853","CDM","983","RC","49322","HCPCS","","","facility","both","","","","1076.5","1076.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colpocleisis (Le Fort Type)","41828854","CDM","983","RC","57120","HCPCS","","","facility","both","","","","1541.34","1541.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colporrhaphy","41828855","CDM","983","RC","57200","HCPCS","","","facility","both","","","","953.57","953.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colpoperineorrhaphy","41828856","CDM","983","RC","57210","HCPCS","","","facility","both","","","","1138.41","1138.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Anterior Colporrhaphy Rep C","41828857","CDM","983","RC","57240","HCPCS","","","facility","both","","","","1773.76","1773.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Comb Anteroposterior Colpor","41828858","CDM","983","RC","57260","HCPCS","","","facility","both","","","","2257.79","2257.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colpopexy Intraperitoneal","41828859","CDM","983","RC","57283","HCPCS","","","facility","both","","","","2046.4","2046.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Rev/Rep Stress Incont Sling","41828860","CDM","983","RC","57287","HCPCS","","","facility","both","","","","2128.05","2128.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Sling Op For Stress Inconti","41828861","CDM","983","RC","57288","HCPCS","","","facility","both","","","","2155.6","2155.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pelvic Examination","41828862","CDM","983","RC","57410","HCPCS","","","facility","both","","","","310.6","310.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Conz Of Cervix W/Scope Leep","41828863","CDM","983","RC","57461","HCPCS","","","facility","both","","","","1065.28","1065.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Conization Of Cervix Cold K","41828864","CDM","983","RC","57520","HCPCS","","","facility","both","","","","1013.73","1013.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Conization Of Cervix Leep","41828865","CDM","983","RC","57522","HCPCS","","","facility","both","","","","867.26","867.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf D C Diagnostic Or Therap No","41828866","CDM","983","RC","58120","HCPCS","","","facility","both","","","","849.34","849.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Total Abdominal Hysterectom","41828867","CDM","983","RC","58150","HCPCS","","","facility","both","","","","2933.9","2933.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subtotal Abd Hysterectomy","41828868","CDM","983","RC","58180","HCPCS","","","facility","both","","","","2789.79","2789.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Chromotubation Of Oviduct","41828869","CDM","983","RC","58350","HCPCS","","","facility","both","","","","398.42","398.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Thermal Endometr Tumor Abl","41828870","CDM","983","RC","58353","HCPCS","","","facility","both","","","","3286.73","3286.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Laparo-Asst Vag Hysterectom","41828871","CDM","983","RC","58550","HCPCS","","","facility","both","","","","2569.7","2569.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Laparo-Vag Hyst Incl T/O =<","41828872","CDM","983","RC","58552","HCPCS","","","facility","both","","","","2860.16","2860.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hysteroscopy Diagnostic","41828873","CDM","983","RC","58555","HCPCS","","","facility","both","","","","1019.68","1019.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hysteroscopy W Lysis Intra","41828874","CDM","983","RC","58559","HCPCS","","","facility","both","","","","827.81","827.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hysteroscopy W Rem Leiomyo","41828875","CDM","983","RC","58561","HCPCS","","","facility","both","","","","1038.76","1038.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hysteroscopy W Endometrial","41828876","CDM","983","RC","58563","HCPCS","","","facility","both","","","","6493.51","6493.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Hysteroscopy  Bilat Sterili","41828877","CDM","983","RC","58565","HCPCS","","","facility","both","","","","5933.64","5933.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ligate Fallop Tube Abd Or V","41828878","CDM","983","RC","58600","HCPCS","","","facility","both","","","","1083.2","1083.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ligate Fallop Tube Abd Vag","41828879","CDM","983","RC","58605","HCPCS","","","facility","both","","","","982.93","982.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ligate Fallopian Tube W Ces","41828880","CDM","983","RC","58611","HCPCS","","","facility","both","","","","219.91","219.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Laparoscopy W Lysis Of Adh","41828881","CDM","983","RC","58660","HCPCS","","","facility","both","","","","1961.51","1961.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W Rem Adnexal Structures","41828882","CDM","983","RC","58661","HCPCS","","","facility","both","","","","1885.42","1885.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap W Exc/Destr Ovary Pelvi","41828883","CDM","983","RC","58662","HCPCS","","","facility","both","","","","2068.45","2068.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap W Occlusion Of Oviducts","41828884","CDM","983","RC","58671","HCPCS","","","facility","both","","","","1084.38","1084.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Salpingectomy Compl/Part Un","41828885","CDM","983","RC","58700","HCPCS","","","facility","both","","","","2301.54","2301.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Salpingo-Oophorectmy  Uni/Bil","41828886","CDM","983","RC","58720","HCPCS","","","facility","both","","","","2177.45","2177.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Adhesiolysis Tube Ovary","41828887","CDM","983","RC","58740","HCPCS","","","facility","both","","","","2602.43","2602.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ovarian Cystectomy Unilater","41828888","CDM","983","RC","58925","HCPCS","","","facility","both","","","","2208.32","2208.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Oophorectomy Part/ Tot Uni","41828889","CDM","983","RC","58940","HCPCS","","","facility","both","","","","1590.75","1590.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lap Tx Ect Preg W Salpinge","41828890","CDM","983","RC","59151","HCPCS","","","facility","both","","","","2160.73","2160.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Curettage Postpartum","41828891","CDM","983","RC","59160","HCPCS","","","facility","both","","","","714.64","714.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cerclage Cervix Pregnant V","41828892","CDM","983","RC","59320","HCPCS","","","facility","both","","","","423.21","423.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginal Delivery Only","41828894","CDM","983","RC","59409","HCPCS","","","facility","both","","","","2248.82","2248.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Delivery Only Incl Pp","41828895","CDM","983","RC","59410","HCPCS","","","facility","both","","","","2913.1","2913.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Delivery Of Placenta","41828896","CDM","983","RC","59414","HCPCS","","","facility","both","","","","251.99","251.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Routine Ob Care Incl Ap C-S","41828897","CDM","983","RC","59510","HCPCS","","","facility","both","","","","6694.76","6694.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Cesarean Delivery Only","41828898","CDM","983","RC","59514","HCPCS","","","facility","both","","","","2525.56","2525.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Surg Tx Incompl Abortion","41828899","CDM","983","RC","59812","HCPCS","","","facility","both","","","","999.23","999.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Surg Tx Missed Abort 1St T","41828900","CDM","983","RC","59820","HCPCS","","","facility","both","","","","1218.72","1218.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Remove Cerclage Suture Unde","41828901","CDM","983","RC","59871","HCPCS","","","facility","both","","","","373.01","373.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc Rem Fb Sq Comp","41828902","CDM","983","RC","10121","HCPCS","","","facility","both","","","","839.6","839.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc Face-Mm B9+Marg 3.1-4 C","41828903","CDM","983","RC","11444","HCPCS","","","facility","both","","","","866.11","866.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Cysto W Ureter/Pyel","41828904","CDM","983","RC","52351","HCPCS","","","facility","both","","","","874.47","874.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation Of Cervical Canal","41828905","CDM","983","RC","57800","HCPCS","","","facility","both","","","","215.22","215.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Poct Basic Metabolic Panel","41828906","CDM","301","RC","80047","HCPCS","","","facility","both","","","QW","32","32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Inonized Calcium (Ca)","41828907","CDM","301","RC","82330","HCPCS","","","facility","both","","","QW","32","32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Tco2","41828908","CDM","301","RC","82374","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Chloride (Cl)","41828909","CDM","301","RC","82435","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Creatinine (Crea)","41828910","CDM","301","RC","82565","HCPCS","","","facility","both","","","QW","12","12","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Potassium (K)","41828912","CDM","301","RC","84132","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Sodium","41828913","CDM","301","RC","84295","HCPCS","","","facility","both","","","QW","11","11","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Urea","41828914","CDM","301","RC","84520","HCPCS","","","facility","both","","","QW","9","9","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hematocrit (Hct)","41828915","CDM","305","RC","85014","HCPCS","","","facility","both","","","QW","7","7","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Hemoglobin (Hb)","41828916","CDM","305","RC","85018","HCPCS","","","facility","both","","","QW","7","7","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Flu","41828917","CDM","300","RC","87804","HCPCS","","","facility","both","","","QW","28","28","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Poct Rapid Rsv","41828918","CDM","306","RC","87807","HCPCS","","","facility","both","","","QW","30","30","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Snellen Eye Test","41828919","CDM","983","RC","99173","HCPCS","","","facility","both","","","","23.39","23.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Care Mgmt 14 Day Disc","41828920","CDM","983","RC","99495","HCPCS","","","facility","both","","","","562.59","562.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Trans Care Mgmt 7 Day Disch","41828921","CDM","983","RC","99496","HCPCS","","","facility","both","","","","742.29","742.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Md Svc Req For Power Mobility","41828924","CDM","983","RC","G0372","HCPCS","","","facility","both","","","","26.8","26.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","41828925","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","41828926","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","41828927","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Pv Residual Urine","41828928","CDM","983","RC","51798","HCPCS","","","facility","both","","","","33.87","33.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41828929","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginal Hysterectomy =<250 Gm","41828931","CDM","983","RC","58260","HCPCS","","","facility","both","","","","2435.83","2435.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Hyst Including T/O =<250 G","41828934","CDM","983","RC","58262","HCPCS","","","facility","both","","","","2697.13","2697.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Routin Ob Care After Vag Deliv","41828935","CDM","983","RC","59610","HCPCS","","","facility","both","","","","6341.4","6341.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Routine Ob Care","41828936","CDM","983","RC","59400","HCPCS","","","facility","both","","","","6084.11","6084.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cesarean Delivery Only Incl P","41828937","CDM","983","RC","59515","HCPCS","","","facility","both","","","","3531.68","3531.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tlh W/T/O 250 G Or Less","41828938","CDM","983","RC","58571","HCPCS","","","facility","both","","","","2613.78","2613.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Laparotomy Expl Celiotomy","41828939","CDM","983","RC","49000","HCPCS","","","facility","both","","","","2205.11","2205.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Bartholin's Gland Or Cy","41828940","CDM","983","RC","56740","HCPCS","","","facility","both","","","","906.22","906.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41828941","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vulvectomy Simple Partial","41828942","CDM","983","RC","56620","HCPCS","","","facility","both","","","","1658.48","1658.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inject Into Skin Lesions =<7","41828943","CDM","983","RC","11900","HCPCS","","","facility","both","","","","171.8","171.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sacrospinous Ligam Fix Prolaps","41828950","CDM","983","RC","57282","HCPCS","","","facility","both","","","","1561.19","1561.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage - Ovarian Cyst(S) Abd","41828951","CDM","983","RC","58805","HCPCS","","","facility","both","","","","1239.22","1239.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Routine Ob Care After Cesarian","41828952","CDM","983","RC","59618","HCPCS","","","facility","both","","","","6769.21","6769.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41828954","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo-Vag Hyst W/T/O Comp>250","41828955","CDM","983","RC","58554","HCPCS","","","facility","both","","","","3808.46","3808.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Maternity Care Del","41828956","CDM","983","RC","59899","HCPCS","","","facility","both","","","","117.3","117.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Vaginal Cyst Or Tumor","41828957","CDM","983","RC","57135","HCPCS","","","facility","both","","","","675.04","675.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41828958","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41828959","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41828960","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41828961","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","41828964","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","41828965","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit I","41828966","CDM","983","RC","99281","HCPCS","","","facility","both","","","","62.85","62.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Ii","41828967","CDM","983","RC","99282","HCPCS","","","facility","both","","","","121.11","121.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iii","41828968","CDM","983","RC","99283","HCPCS","","","facility","both","","","","180.92","180.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","41828969","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","41828970","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Anal Les Simple Laser","41828971","CDM","983","RC","46917","HCPCS","","","facility","both","","","","1368.2","1368.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colposcopy Of Vulva","41828972","CDM","983","RC","56820","HCPCS","","","facility","both","","","","360.89","360.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vulva Colposc W Bx","41828973","CDM","983","RC","56821","HCPCS","","","facility","both","","","","479.74","479.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fbp W Non-Stress Test","41828974","CDM","983","RC","76818","HCPCS","","","facility","both","","","","372.16","372.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W Destruction Of Oviducts","41828975","CDM","983","RC","58670","HCPCS","","","facility","both","","","","1086.03","1086.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo-Vag Hyst Comp >250Gm","41828976","CDM","983","RC","58553","HCPCS","","","facility","both","","","","3260.54","3260.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Myomectomy=<250Gm","41828977","CDM","983","RC","58545","HCPCS","","","facility","both","","","","2609.66","2609.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Myomectomy Comp>250Gm","41828978","CDM","983","RC","58546","HCPCS","","","facility","both","","","","3241.8","3241.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Enterolysis","41828979","CDM","983","RC","44180","HCPCS","","","facility","both","","","","2624.54","2624.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Appendectomy","41828980","CDM","983","RC","44970","HCPCS","","","facility","both","","","","1729.8","1729.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo W/Salpingostomy","41828981","CDM","983","RC","58673","HCPCS","","","facility","both","","","","2312.79","2312.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colpopexy Laparoscopy","41828982","CDM","983","RC","57425","HCPCS","","","facility","both","","","","2846.66","2846.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy W Fimbrioplasty","41828983","CDM","983","RC","58672","HCPCS","","","facility","both","","","","2129.63","2129.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hysteroscopy W Intraut Septum","41828984","CDM","983","RC","58560","HCPCS","","","facility","both","","","","908.98","908.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lysis Of Labial Adhesions","41828985","CDM","983","RC","56441","HCPCS","","","facility","both","","","","501.2","501.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vulvectomy Simpl Complete","41828986","CDM","983","RC","56625","HCPCS","","","facility","both","","","","1910.39","1910.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hymenotomy","41828987","CDM","983","RC","56442","HCPCS","","","facility","both","","","","140.27","140.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plastic Repair Of Introitus","41828988","CDM","983","RC","56800","HCPCS","","","facility","both","","","","730.87","730.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perineoplasty Perineum Non-Ob","41828989","CDM","983","RC","56810","HCPCS","","","facility","both","","","","786.17","786.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colpotomy W Exploration","41828990","CDM","983","RC","57000","HCPCS","","","facility","both","","","","581.74","581.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colpotomy W Drain Pelvic Abs","41828991","CDM","983","RC","57010","HCPCS","","","facility","both","","","","1326.33","1326.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colpocentesis","41828992","CDM","983","RC","57020","HCPCS","","","facility","both","","","","329.11","329.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Vag Lesions Complex","41828993","CDM","983","RC","57065","HCPCS","","","facility","both","","","","674.67","674.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx Vaginal Mucosa Extensive","41828994","CDM","983","RC","57105","HCPCS","","","facility","both","","","","488.58","488.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginectomy W P Rem Of Vag Wal","41828995","CDM","983","RC","57106","HCPCS","","","facility","both","","","","1538.41","1538.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Radical Vaginectomy","41828996","CDM","983","RC","57107","HCPCS","","","facility","both","","","","4184.45","4184.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Vaginal Septum","41828997","CDM","983","RC","57130","HCPCS","","","facility","both","","","","628.48","628.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Irrigate Vagina W Meds","41828998","CDM","983","RC","57150","HCPCS","","","facility","both","","","","166.89","166.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrl Non-Ob Vag Hemorrhage","41828999","CDM","983","RC","57180","HCPCS","","","facility","both","","","","540.49","540.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Urethral Sphincter Vaginal","41829000","CDM","983","RC","57220","HCPCS","","","facility","both","","","","1000.03","1000.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plastic Repair Of Urethrocele","41829001","CDM","983","RC","57230","HCPCS","","","facility","both","","","","1212.02","1212.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Posterior Colporrhaphy-Recto","41829002","CDM","983","RC","57250","HCPCS","","","facility","both","","","","1781.72","1781.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Enterocele Vaginal","41829003","CDM","983","RC","57268","HCPCS","","","facility","both","","","","1473.75","1473.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Enterocele Abdominal","41829004","CDM","983","RC","57270","HCPCS","","","facility","both","","","","2362.34","2362.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colpopexy Abdominal Approach","41829005","CDM","983","RC","57280","HCPCS","","","facility","both","","","","2803.45","2803.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Paravag Defect Open","41829006","CDM","983","RC","57284","HCPCS","","","facility","both","","","","2409.46","2409.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Rectovaginal Fist Vag","41829007","CDM","983","RC","57300","HCPCS","","","facility","both","","","","1748.53","1748.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Rectovaginal Fist Abd","41829008","CDM","983","RC","57305","HCPCS","","","facility","both","","","","2811.2","2811.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Urethrovaginal Fistula","41829009","CDM","983","RC","57310","HCPCS","","","facility","both","","","","1431.93","1431.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Vesicovaginal Fistula Va","41829010","CDM","983","RC","57320","HCPCS","","","facility","both","","","","1624","1624","","","","","","","","","","","","","Gross Charge Type: Standard"
"Close Vesicovag Fistula Transv","41829011","CDM","983","RC","57330","HCPCS","","","facility","both","","","","2228.66","2228.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vaginoplasty For Intersex Stat","41829012","CDM","983","RC","57335","HCPCS","","","facility","both","","","","3411.69","3411.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilation Of Vagina","41829013","CDM","983","RC","57400","HCPCS","","","facility","both","","","","382.37","382.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cautery Of Cervix Laser Ablati","41829014","CDM","983","RC","57513","HCPCS","","","facility","both","","","","543.38","543.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Cervical Stump Abdomina","41829015","CDM","983","RC","57540","HCPCS","","","facility","both","","","","2299.99","2299.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Cerv Stump Abd W Pelv Flr","41829016","CDM","983","RC","57545","HCPCS","","","facility","both","","","","2421.79","2421.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Cervical Stump Vaginal","41829017","CDM","983","RC","57550","HCPCS","","","facility","both","","","","1251.04","1251.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Cerv Stump Vag Ant Post Re","41829018","CDM","983","RC","57555","HCPCS","","","facility","both","","","","1798.79","1798.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Cerv Stump Vag Enterocele","41829019","CDM","983","RC","57556","HCPCS","","","facility","both","","","","1706.61","1706.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41829020","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41829021","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41829022","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41829023","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41829025","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41829026","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41829027","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41829028","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41829029","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41829030","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41829031","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41829032","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41829033","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41829034","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41829035","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41829036","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41829037","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41829038","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41829039","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screening For Depression","41829040","CDM","983","RC","3725F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41829041","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Remove Drug Implant","41829042","CDM","983","RC","11982","HCPCS","","","facility","both","","","","355.07","355.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Flu Virus Vaccine","41829043","CDM","771","RC","G0008","HCPCS","","","facility","both","","","","100","100","","","","","","","","","","","","","Gross Charge Type: Standard"
"Admin Pneumococcal Vacc","41829044","CDM","771","RC","G0009","HCPCS","","","facility","both","","","","193","193","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Skene's Glnd/Abscss/Cyst","41829045","CDM","983","RC","53060","HCPCS","","","facility","both","","","","555.41","555.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Induced Abortion By Dil Evac","41829046","CDM","983","RC","59841","HCPCS","","","facility","both","","","","1173.74","1173.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tlh W/T/O Uterus Over 250 G","41829047","CDM","983","RC","58573","HCPCS","","","facility","both","","","","3514.03","3514.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Hyst W T O Complx  250 Gm","41829048","CDM","983","RC","58291","HCPCS","","","facility","both","","","","3624.02","3624.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Delivery After Cesarian","41829050","CDM","983","RC","59612","HCPCS","","","facility","both","","","","2516.77","2516.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Preventive Counseling 15 Min","41829051","CDM","983","RC","99401","HCPCS","","","facility","both","","","","49.11","49.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guide Intraoperative","41829054","CDM","983","RC","76998","HCPCS","","","facility","both","","","","174.74","174.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myomectomy Abd 1-4 Myomas","41829055","CDM","983","RC","58140","HCPCS","","","facility","both","","","","2697.31","2697.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Physician Standby Ea 30 Min","41829056","CDM","983","RC","99360","HCPCS","","","facility","both","","","","257.5","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Genetic Counseling 30 Mins","41829057","CDM","983","RC","96040","HCPCS","","","facility","both","","","","141.63","141.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Genetic Counseling 15 Mins","41829058","CDM","983","RC","S0265","HCPCS","","","facility","both","","","","70.81","70.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amniocentesis Diagnostic","41829059","CDM","983","RC","59000","HCPCS","","","facility","both","","","","361.63","361.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chorionic Villus Sampling","41829060","CDM","983","RC","59015","HCPCS","","","facility","both","","","","448.87","448.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Cvs","41829061","CDM","983","RC","76945","HCPCS","","","facility","both","","","","96.97","96.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Amniocentesis","41829062","CDM","983","RC","76946","HCPCS","","","facility","both","","","","99.34","99.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Maternity/Deliv","41829063","CDM","983","RC","59899","HCPCS","","","facility","both","","","","696.64","696.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tlh Uterus 250 G Or Less","41829064","CDM","983","RC","58570","HCPCS","","","facility","both","","","","2316.44","2316.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ob Us Nuchal Meas Add-On","41829065","CDM","983","RC","76814","HCPCS","","","facility","both","","","","241.69","241.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Tx Ect Preg Wo Salpingecto","41829068","CDM","983","RC","59150","HCPCS","","","facility","both","","","","2217.8","2217.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Female Genital","41829070","CDM","983","RC","58999","HCPCS","","","facility","both","","","","930.48","930.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Induced Abortion By D C","41829071","CDM","983","RC","59840","HCPCS","","","facility","both","","","","692.59","692.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41829072","CDM","983","RC","99091","HCPCS","","","facility","both","","","","167.3","167.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mntr Physiol Param Setup","41829073","CDM","983","RC","99453","HCPCS","","","facility","both","","","","61.31","61.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41829076","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surg Tx Septic Abortion","41829079","CDM","983","RC","59830","HCPCS","","","facility","both","","","","1297.13","1297.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Del After Cesarian +Postop","41829080","CDM","983","RC","59614","HCPCS","","","facility","both","","","","3137.86","3137.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cesarean Delv Post Vag Attempt","41829081","CDM","983","RC","59620","HCPCS","","","facility","both","","","","2606.38","2606.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hysterorrhaphy Ruptured Uterus","41829082","CDM","983","RC","59350","HCPCS","","","facility","both","","","","772.26","772.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Est Pt Level I","41829083","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41829084","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41829085","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41829086","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41829087","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Myomectomy Abd Comp 5 Myomas","41829088","CDM","983","RC","58146","HCPCS","","","facility","both","","","","3355.38","3355.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Tum Over 10 Cm","41829089","CDM","983","RC","49205","HCPCS","","","facility","both","","","","4974.57","4974.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 5-10 Mins","41829091","CDM","983","RC","99421","HCPCS","","","facility","both","","","","44.73","44.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11-20 Mins","41829092","CDM","983","RC","99422","HCPCS","","","facility","both","","","","88.71","88.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41829093","CDM","983","RC","99423","HCPCS","","","facility","both","","","","143.61","143.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehisc Smpl","41829094","CDM","983","RC","12020","HCPCS","","","facility","both","","","","917.11","917.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv/Hosp Same Date Ii 50 Min","41829095","CDM","983","RC","99235","HCPCS","","","facility","both","","","","485.92","485.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observ/Hosp Same Date Lvl I","41829096","CDM","983","RC","99234","HCPCS","","","facility","both","","","","381.98","381.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Lap Oviduct Ovary","41829097","CDM","983","RC","58679","HCPCS","","","facility","both","","","","1053.77","1053.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Partial Hymenectomy/Revision","41829098","CDM","983","RC","56700","HCPCS","","","facility","both","","","","571.89","571.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41829100","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41829101","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41829102","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41829103","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41829105","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41829106","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41829107","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Vag Hyst W/Urinary Repr=<250Gm","41829108","CDM","983","RC","58267","HCPCS","","","facility","both","","","","3036.47","3036.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ect Preg Tub Ov Req Salp Ooph","41829109","CDM","983","RC","59120","HCPCS","","","facility","both","","","","2239.3","2239.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Int Nutri Ther Ea","41829110","CDM","983","RC","97802","HCPCS","","","facility","both","","","95","114.15","114.15","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Reassess Nuti Tx","41829111","CDM","983","RC","97803","HCPCS","","","facility","both","","","95","99.09","99.09","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Mnt,Group,Ea 30Min","41829112","CDM","983","RC","97804","HCPCS","","","facility","both","","","95","51.42","51.42","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41829114","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41829115","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41829116","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41829117","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Remove Drug Implant","41829119","CDM","983","RC","11982","HCPCS","","","facility","both","","","","355.07","355.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap W Destruction Of Oviducts","41829120","CDM","983","RC","58670","HCPCS","","","facility","both","","","","1086.03","1086.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ect Preg Tub Ov Req Salp Ooph","41829121","CDM","983","RC","59120","HCPCS","","","facility","both","","","","2239.3","2239.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Skin Bone At Fx Site","41829122","CDM","983","RC","11012","HCPCS","","","facility","both","","","","2074.13","2074.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Att F C M N A G H F 10.1 30Sq","41829123","CDM","983","RC","14041","HCPCS","","","facility","both","","","","2834.89","2834.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Bone Superficial","41829124","CDM","983","RC","20220","HCPCS","","","facility","both","","","","796.65","796.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M By Phys 5-10M","41829125","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41829126","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41829127","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M By Phys 5-10M","41829128","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41829129","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41829130","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Lg Int Wnd Inj W Colostomy","41829131","CDM","983","RC","44605","HCPCS","","","facility","both","","","","3640.84","3640.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Recon Vena Cava Any Method","41829132","CDM","983","RC","34502","HCPCS","","","facility","both","","","","4238.69","4238.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Adv Care 30 Min","41829133","CDM","983","RC","99497","HCPCS","","","facility","both","","","95","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care Plan 30M","41829134","CDM","983","RC","99498","HCPCS","","","facility","both","","","95","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alcohol Misuse 15M","41829135","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41829136","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn 15","41829137","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41829138","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41829139","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41829140","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41829141","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41829142","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Suture Bladder Wound Inj Comp","41829143","CDM","983","RC","51865","HCPCS","","","facility","both","","","","2619.17","2619.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Myomectomy Vag 1-4 Myomas","41829144","CDM","983","RC","58145","HCPCS","","","facility","both","","","","1652.94","1652.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uterine Evac/Curett-Hydatiform","41829145","CDM","983","RC","59870","HCPCS","","","facility","both","","","","1452.15","1452.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"D C Of Cervical Stump","41829146","CDM","983","RC","57558","HCPCS","","","facility","both","","","","427.48","427.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 7.0%<8.0%","41829147","CDM","983","RC","3051F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 8.0%","41829148","CDM","983","RC","3052F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lcl Surg Wnd/Deh Extens","41829150","CDM","983","RC","13160","HCPCS","","","facility","both","","","","2344.9","2344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sub/Tot Hysterectomy After Ces","41829151","CDM","983","RC","59525","HCPCS","","","facility","both","","","","1310.31","1310.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Non-Tunneled Cv Cath","41829152","CDM","983","RC","36580","HCPCS","","","facility","both","","","","682.25","682.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl Postop Hemor Thromb Inf A","41829153","CDM","983","RC","35840","HCPCS","","","facility","both","","","","3386.09","3386.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Hidrad Ing S I Repair","41829154","CDM","983","RC","11462","HCPCS","","","facility","both","","","","1210.82","1210.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vag Hyst W T O Vag Repr 250Gm","41829155","CDM","983","RC","58263","HCPCS","","","facility","both","","","","2831.96","2831.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Major Artery Abdomen","41829156","CDM","983","RC","37617","HCPCS","","","facility","both","","","","3740.86","3740.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Postpartum F/U","41829157","CDM","983","RC","Z1038","HCPCS","","","facility","both","","","95","231.52","231.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Lap Cholecystectomy W Chol","41829158","CDM","983","RC","47563","HCPCS","","","facility","both","","","","2055.83","2055.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Antepartum Tenth Subsq Visit","41829160","CDM","983","RC","Z1036","HCPCS","","","facility","both","","","","432.64","432.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Guided Needle Placement","41829161","CDM","983","RC","76942","HCPCS","","","facility","both","","","26","176.65","176.65","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Stress Test Non-Fetal (Clinic)","41829162","CDM","983","RC","59025","HCPCS","","","facility","both","","","","143.76","143.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Les Sc 3 Cm/>","41829163","CDM","983","RC","22903","HCPCS","","","facility","both","","","","1278.59","1278.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Pudendal Nerve","41829164","CDM","983","RC","64430","HCPCS","","","facility","both","","","","278.08","278.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Cerclage Suture Under Anes","41829165","CDM","983","RC","59871","HCPCS","","","facility","both","","","","354.76","354.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Paravag Defect Vag","41829166","CDM","983","RC","57285","HCPCS","","","facility","both","","","","1942.56","1942.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Rectocele","41829167","CDM","983","RC","45560","HCPCS","","","facility","both","","","","1937.56","1937.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Closure Rectourethral Fistula","41829168","CDM","983","RC","45820","HCPCS","","","facility","both","","","","3499.48","3499.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remval Of Omentum, Epiploectmy","41829169","CDM","983","RC","49255","HCPCS","","","facility","both","","","","2187.75","2187.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim No Prog","41829170","CDM","983","RC","95970","HCPCS","","","facility","both","","","","56.27","56.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Scrotum And Contents","41829171","CDM","983","RC","76870","HCPCS","","","facility","both","","","","269.72","269.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Attach Bladder/Urethra","41829172","CDM","983","RC","51840","HCPCS","","","facility","both","","","","1948.38","1948.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Orchiectomy","41829173","CDM","983","RC","54690","HCPCS","","","facility","both","","","","1826.19","1826.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Penile Tumescence Rigidity Tst","41829174","CDM","983","RC","54250","HCPCS","","","facility","both","","","","341.37","341.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Blddr Cyst W/Wo Umb Hrn Rp","41829175","CDM","983","RC","51500","HCPCS","","","facility","both","","","","1781.8","1781.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Mesh From Abd Wall","41829176","CDM","983","RC","11008","HCPCS","","","facility","both","","","","726.54","726.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Ablt Uterine Fibroids W/Us","41829177","CDM","983","RC","58674","HCPCS","","","facility","both","","","","2268.63","2268.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W/Res Ectopc Ureterocele","41829178","CDM","983","RC","52301","HCPCS","","","facility","both","","","","792.64","792.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W/Urt W/Tx Urt Jnt Strix","41829179","CDM","983","RC","52345","HCPCS","","","facility","both","","","","1076.02","1076.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystouretero W/Excise Tumor","41829180","CDM","983","RC","52355","HCPCS","","","facility","both","","","","1273.44","1273.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Urethra Lesion","41829181","CDM","983","RC","53235","HCPCS","","","facility","both","","","","1771.96","1771.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Urethra Defect","41829182","CDM","983","RC","53275","HCPCS","","","facility","both","","","","732.46","732.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Penis Lesion","41829183","CDM","983","RC","54015","HCPCS","","","facility","both","","","","851.4","851.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Kidney Ureter","41829184","CDM","983","RC","50236","HCPCS","","","facility","both","","","","4048.03","4048.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Bladder Lesion","41829185","CDM","983","RC","51525","HCPCS","","","facility","both","","","","2386.51","2386.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Ligate Spermatic Vein","41829186","CDM","983","RC","55550","HCPCS","","","facility","both","","","","1206.88","1206.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Ablate Renal Cyst","41829187","CDM","983","RC","50541","HCPCS","","","facility","both","","","","2536.97","2536.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparo Remove W/Ureter","41829188","CDM","983","RC","50548","HCPCS","","","facility","both","","","","3696.82","3696.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Change Nephroureteral Cath","41829189","CDM","983","RC","50387","HCPCS","","","facility","both","","","","1859.05","1859.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv Hosp Same Date Iii 55 Min","41829190","CDM","983","RC","99236","HCPCS","","","facility","both","","","","624.59","624.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Appendix Abscess Open","41829191","CDM","983","RC","44900","HCPCS","","","facility","both","","","","2153.68","2153.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Stomach-Bowel Fusion","41829192","CDM","983","RC","43860","HCPCS","","","facility","both","","","","4437.6","4437.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Missed Abortn 2Nd Tri Surg","41829193","CDM","983","RC","59821","HCPCS","","","facility","both","","","","1239.69","1239.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Colon","41829194","CDM","983","RC","45399","HCPCS","","","facility","both","","","","2885.06","2885.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Care Mgmt 14 Day Disc","41829195","CDM","983","RC","99495","HCPCS","","","facility","both","","","","562.59","562.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ureterolysis Retroperit Fibros","41829196","CDM","983","RC","50715","HCPCS","","","facility","both","","","","3309.32","3309.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Uterus","41829197","CDM","983","RC","58578","HCPCS","","","facility","both","","","","1329.76","1329.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Mri Procedure","41829198","CDM","983","RC","76498","HCPCS","","","facility","both","","","26","759.99","759.99","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Prolonged E/M Service Ea 15Min","41829199","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cystography Min 3 Views Rs I","41829200","CDM","983","RC","74430","HCPCS","","","facility","both","","","26","125.25","125.25","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Us Exam Pelvic Complete","41829201","CDM","983","RC","76856","HCPCS","","","facility","both","","","26","351.62","351.62","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Urethotomy Perineal","41829202","CDM","983","RC","53010","HCPCS","","","facility","both","","","","841.59","841.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Of Rectal Abscess","41829203","CDM","983","RC","45020","HCPCS","","","facility","both","","","","1613.32","1613.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracotomy W Rem Intrapulm Fb","41829204","CDM","983","RC","32151","HCPCS","","","facility","both","","","","2692.09","2692.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Fulgrtn Urethral Caruncle","41829206","CDM","983","RC","53265","HCPCS","","","facility","both","","","","659.49","659.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Tx Othr Periperal Ne","41829207","CDM","983","RC","64640","HCPCS","","","facility","both","","","","787.41","787.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intestinal Plication Surgical","41829208","CDM","983","RC","44680","HCPCS","","","facility","both","","","","2926.49","2926.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Thigh Pressure Sore","41829209","CDM","983","RC","15956","HCPCS","","","facility","both","","","","3304.5","3304.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Umbilical Lesion","41829210","CDM","983","RC","49605","HCPCS","","","facility","both","","","","13148.1","13148.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Lower Jaw Fracture","41829211","CDM","983","RC","21451","HCPCS","","","facility","both","","","","2401.68","2401.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Init Fem Hernia Reducible","41829212","CDM","983","RC","49550","HCPCS","","","facility","both","","","","1595.06","1595.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto W Steroid Inj Stricture","41829213","CDM","983","RC","52283","HCPCS","","","facility","both","","","","1037.83","1037.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Lap Px Lymphatic Sys","41829214","CDM","983","RC","38589","HCPCS","","","facility","both","","","","3237.78","3237.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Lap Px Spermatic Cord","41829215","CDM","983","RC","55559","HCPCS","","","facility","both","","","","1282.23","1282.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Deep Rx Delivery Device","41829216","CDM","983","RC","20701","HCPCS","","","facility","both","","","","221.6","221.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Bypass For Obesity","41829217","CDM","983","RC","43846","HCPCS","","","facility","both","","","","4493.71","4493.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41829219","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Wedge/Bx Lung Infiltr","41829220","CDM","983","RC","32096","HCPCS","","","facility","both","","","","2135.24","2135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orchiopexy Abdl Apprch Testis","41829221","CDM","983","RC","54650","HCPCS","","","facility","both","","","","1978.61","1978.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laparoscopy Orchiopexy","41829222","CDM","983","RC","54692","HCPCS","","","facility","both","","","","2084.65","2084.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Hernia Sperm Veins","41829223","CDM","983","RC","55540","HCPCS","","","facility","both","","","","1542.25","1542.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transvaginal Us Non-Ob","41829224","CDM","983","RC","76830","HCPCS","","","facility","both","","","","378.45","378.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Pancreas Open","41829225","CDM","983","RC","48100","HCPCS","","","facility","both","","","","2411.26","2411.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Windpipe Opening","41829226","CDM","983","RC","31613","HCPCS","","","facility","both","","","","1267.47","1267.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy Of Liver","41829227","CDM","983","RC","47000","HCPCS","","","facility","both","","","","964.29","964.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Complex","41829228","CDM","983","RC","95972","HCPCS","","","facility","both","","","","170.28","170.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sweat Gland Lesion","41829229","CDM","983","RC","11463","HCPCS","","","facility","both","","","","1627.84","1627.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Ureteral Stent Prq","41829230","CDM","983","RC","50693","HCPCS","","","facility","both","","","","3258.56","3258.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Lung Lesion(S)","41829231","CDM","983","RC","32150","HCPCS","","","facility","both","","","","2720.83","2720.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Arm Foreign Body","41829232","CDM","983","RC","24201","HCPCS","","","facility","both","","","","1652.84","1652.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Sacrum Pressure Sore","41829233","CDM","983","RC","15936","HCPCS","","","facility","both","","","","2538.52","2538.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Sweat Gland Lesion","41829234","CDM","983","RC","11471","HCPCS","","","facility","both","","","","1646.79","1646.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Full Graft Sclp/Arm/Leg","41829235","CDM","983","RC","15220","HCPCS","","","facility","both","","","","2271.23","2271.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Full Graft Add-On","41829236","CDM","983","RC","15221","HCPCS","","","facility","both","","","","394.75","394.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Radiation Therapy Field","41829237","CDM","983","RC","77280","HCPCS","","","facility","both","","","","851.22","851.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Radiation Therapy Field","41829238","CDM","983","RC","77285","HCPCS","","","facility","both","","","","1410.41","1410.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Mesh/Pelvic Flr Addon","41829239","CDM","983","RC","57267","HCPCS","","","facility","both","","","","680.29","680.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lprscpy Slng Oprtn Strss Incnt","41829240","CDM","983","RC","51992","HCPCS","","","facility","both","","","","921.74","921.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Bld Vssl Drct Intr-Abd","41829241","CDM","983","RC","35221","HCPCS","","","facility","both","","","","3778.48","3778.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Of Rectal Abscess","41829242","CDM","983","RC","45005","HCPCS","","","facility","both","","","","398.73","398.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscope W/Submuc Inj","41829243","CDM","983","RC","45335","HCPCS","","","facility","both","","","","381.79","381.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prtl Thyrd Lbctmy Uni W/Wo Ist","41829244","CDM","983","RC","60210","HCPCS","","","facility","both","","","","787.15","787.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Fb Removal","41829245","CDM","983","RC","45379","HCPCS","","","facility","both","","","","1340.18","1340.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Cmplt Csf Shnt W/Rplcmt S","41829246","CDM","983","RC","62258","HCPCS","","","facility","both","","","","1179.58","1179.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excsn H/P/P/U Cmplx Rpr","41829247","CDM","983","RC","11471","HCPCS","","","facility","both","","","","642.4","642.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Sacrum Pressure Sore","41829248","CDM","983","RC","15937","HCPCS","","","facility","both","","","","2894.56","2894.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrotoplasty Simple","41829249","CDM","983","RC","55175","HCPCS","","","facility","both","","","","1013.16","1013.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Tiss Rearrang 30.1-60.0 Sq","41829250","CDM","983","RC","14301","HCPCS","","","facility","both","","","","3134.73","3134.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Guidance Ndl Plmt Rs I","41829251","CDM","983","RC","77021","HCPCS","","","facility","both","","","","193.1","193.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hernia 1St < 3 Cm Rdcbl","41829252","CDM","983","RC","49591","HCPCS","","","facility","both","","","","916.19","916.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn <3Cm Ncrc8/Strnfltd","41829253","CDM","983","RC","49592","HCPCS","","","facility","both","","","","1267.16","1267.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hernia 1St 3-10 Cm Rdcb","41829254","CDM","983","RC","49593","HCPCS","","","facility","both","","","","1526.49","1526.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Mlgnnt Lsn F/E/E/N/L >4.0C","41829255","CDM","983","RC","11646","HCPCS","","","facility","both","","","","1488.04","1488.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Mckl Dvrtclm/Ompmsntrc Dct","41829256","CDM","983","RC","44800","HCPCS","","","facility","both","","","","2144","2144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Vgnl Cyst/Tmr","41829257","CDM","983","RC","57135","HCPCS","","","facility","both","","","","747.57","747.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trach Tube Chg Pre Fistula","41829258","CDM","983","RC","31502","HCPCS","","","facility","both","","","","100.58","100.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Nninfct Msh Aa Prstml Hrn","41829259","CDM","983","RC","49623","HCPCS","","","facility","both","","","","525.4","525.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Parastomal Hrna Ncr Strn","41829260","CDM","983","RC","49622","HCPCS","","","facility","both","","","","2447.62","2447.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Parastomal Hernia Rdc","41829261","CDM","983","RC","49621","HCPCS","","","facility","both","","","","1985.84","1985.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 10 Ncr Strn","41829262","CDM","983","RC","49618","HCPCS","","","facility","both","","","","3290.52","3290.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 10 Rdc","41829263","CDM","983","RC","49617","HCPCS","","","facility","both","","","","2355.97","2355.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 3-10 Ncr Strn","41829264","CDM","983","RC","49616","HCPCS","","","facility","both","","","","2279.94","2279.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 3-10 Rdc","41829265","CDM","983","RC","49615","HCPCS","","","facility","both","","","","1702.95","1702.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 3 Ncr Strn","41829266","CDM","983","RC","49614","HCPCS","","","facility","both","","","","1522.27","1522.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn Rcr 3 Rdc","41829267","CDM","983","RC","49613","HCPCS","","","facility","both","","","","1128.81","1128.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn 1St 10 Ncr Strn","41829268","CDM","983","RC","49596","HCPCS","","","facility","both","","","","2718.66","2718.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn 1St 10 Rdc","41829269","CDM","983","RC","49595","HCPCS","","","facility","both","","","","2049.13","2049.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Aa Hrn 1St 3-10 Ncr Strn","41829270","CDM","983","RC","49594","HCPCS","","","facility","both","","","","1981.34","1981.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnscrvcl Cthj Fllpn Tb Rs I","41829272","CDM","983","RC","74742","HCPCS","","","facility","both","","","","81.94","81.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trnscrv Flpn Tb W/Wo Hystslpng","41829273","CDM","983","RC","58345","HCPCS","","","facility","both","","","","818.52","818.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cntrl Orphryngl Hem-Req Surg","41829274","CDM","983","RC","42962","HCPCS","","","facility","both","","","","1514.05","1514.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colostomy With Biopsies","41829275","CDM","983","RC","44322","HCPCS","","","facility","both","","","","2848.86","2848.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Escharotomy First Incision","41829276","CDM","983","RC","16035","HCPCS","","","facility","both","","","","529.32","529.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Espg/Gstr Tmpnd W/Bl Sngstkn","41829277","CDM","983","RC","43460","HCPCS","","","facility","both","","","","587.05","587.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Tunneled Cv Cath","41829278","CDM","983","RC","36575","HCPCS","","","facility","both","","","","462.91","462.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompression Of Lower Leg","41829279","CDM","983","RC","27601","HCPCS","","","facility","both","","","","1272.39","1272.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","41829280","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","41829281","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Ectopic Pregnancy","41829283","CDM","983","RC","59140","HCPCS","","","facility","both","","","","1161.53","1161.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ntrprof Ph1/Ntrnet/Efr 21-30","41829284","CDM","983","RC","99448","HCPCS","","","facility","both","","","","150.23","150.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prostate Saturation Sampling","41829285","CDM","983","RC","55706","HCPCS","","","facility","both","","","","1060.64","1060.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Malgnt Lesion >4.0 Cm","41829286","CDM","983","RC","11626","HCPCS","","","facility","both","","","","1208.58","1208.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Measure Blood Oxygen Level","41829287","CDM","983","RC","94761","HCPCS","","","facility","both","","","","11.46","11.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged Svcs W/O Contact","41829288","CDM","983","RC","99358","HCPCS","","","facility","both","","","","323.32","323.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exploration Of Chest","41829289","CDM","983","RC","39010","HCPCS","","","facility","both","","","","2117.47","2117.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Colon/Ileostomy","41829290","CDM","983","RC","44151","HCPCS","","","facility","both","","","","5827.28","5827.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Abdominal Mass","41829291","CDM","983","RC","49180","HCPCS","","","facility","both","","","","534.98","534.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Catheter In Vein","41829292","CDM","983","RC","36011","HCPCS","","","facility","both","","","","2583.55","2583.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Urethra Stricture","41829293","CDM","983","RC","53601","HCPCS","","","facility","both","","","","253.93","253.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Serv W/O Contact Add","41829294","CDM","983","RC","99359","HCPCS","","","facility","both","","","","157.4","157.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cytoscopy With Biopsy","41829295","CDM","983","RC","52204","HCPCS","","","facility","both","","","","1233.79","1233.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Suture Bladder Wound Simple","41829296","CDM","983","RC","51860","HCPCS","","","facility","both","","","","2076.74","2076.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Excessive Skin Thigh","41829297","CDM","983","RC","15832","HCPCS","","","facility","both","","","","2642.34","2642.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Groin Lymph Nodes","41829298","CDM","983","RC","38760","HCPCS","","","facility","both","","","","2313.12","2313.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Tlh Uterus Over 250 G","41829299","CDM","983","RC","58572","HCPCS","","","facility","both","","","","2902.61","2902.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Int/Ext Hem 1 Group","41829300","CDM","983","RC","46255","HCPCS","","","facility","both","","","","1577.53","1577.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Forarm/Wrist Tum 3Cm>","41829301","CDM","983","RC","25078","HCPCS","","","facility","both","","","","3262.63","3262.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Forearm/Wrist Tum<3Cm","41829302","CDM","983","RC","25077","HCPCS","","","facility","both","","","","2513.92","2513.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompress Small Bowel","41829303","CDM","983","RC","44021","HCPCS","","","facility","both","","","","2637.14","2637.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Partial Removal Of Colon","41829304","CDM","983","RC","44147","HCPCS","","","facility","both","","","","5190.94","5190.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Neck Thorax Tumor<5Cm","41829305","CDM","983","RC","21557","HCPCS","","","facility","both","","","","2671.59","2671.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Shoulder Tumor < 5 Cm","41829306","CDM","983","RC","23077","HCPCS","","","facility","both","","","","3116.14","3116.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Shoulder Tumor 5 Cm/>","41829307","CDM","983","RC","23078","HCPCS","","","facility","both","","","","3970.58","3970.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Ch Wal Tum W/O Lymphadec","41829308","CDM","983","RC","21602","HCPCS","","","facility","both","","","","4295.31","4295.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Nasal Foreign Body","41829309","CDM","983","RC","30310","HCPCS","","","facility","both","","","","639.56","639.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Anal Sphincter","41829310","CDM","983","RC","46750","HCPCS","","","facility","both","","","","2112.48","2112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr F/C/C/M/N/A/G/H/F","41829311","CDM","983","RC","14040","HCPCS","","","facility","both","","","","2272.64","2272.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Lower Leg At Knee","41829312","CDM","983","RC","27598","HCPCS","","","facility","both","","","","1907.15","1907.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Correct Rectal Prolapse","41829313","CDM","983","RC","45540","HCPCS","","","facility","both","","","","2910.35","2910.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Colon/Ileostomy","41829314","CDM","983","RC","44155","HCPCS","","","facility","both","","","","5655.61","5655.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Back Tum 5 Cm/>","41829315","CDM","983","RC","21936","HCPCS","","","facility","both","","","","3885.78","3885.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Face/Scalp Tum 2 Cm/>","41829316","CDM","983","RC","21016","HCPCS","","","facility","both","","","","2854.28","2854.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Abdomen Lymph Nodes","41829317","CDM","983","RC","38780","HCPCS","","","facility","both","","","","2877.59","2877.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Of Bile Duct Cyst","41829318","CDM","983","RC","47715","HCPCS","","","facility","both","","","","3623.83","3623.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Mcp Disloc Sgl W Manip","41829319","CDM","983","RC","26700","HCPCS","","","facility","both","","","","1034.38","1034.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Surg Prst8Ect Smpl Stot","41829320","CDM","983","RC","55867","HCPCS","","","facility","both","","","","2886.86","2886.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Cervix","41829321","CDM","983","RC","57530","HCPCS","","","facility","both","","","","1086.8","1086.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Neck Tumor 5 Cm/>","41829322","CDM","983","RC","21558","HCPCS","","","facility","both","","","","3718.4","3718.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interdental Fixation","41829323","CDM","983","RC","21110","HCPCS","","","facility","both","","","","2714.34","2714.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Of Rib Fracture","41829324","CDM","983","RC","21812","HCPCS","","","facility","both","","","","1903.13","1903.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Forearm Decompressn Fasciotomy","41829325","CDM","983","RC","24495","HCPCS","","","facility","both","","","","2821.17","2821.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Extraction Erupted Tooth/Exr","41829326","CDM","983","RC","D7140","HCPCS","","","facility","both","","","","2905.42","2905.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx < = 50Sq Cm","41829327","CDM","983","RC","97607","HCPCS","","","facility","both","","","","1197.41","1197.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Echo Transthoracic","41829328","CDM","983","RC","93304","HCPCS","","","facility","both","","","","100.3","100.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Mesentery","41829329","CDM","983","RC","44850","HCPCS","","","facility","both","","","","2046.18","2046.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr S/A/L 10 Sq Cm/<","41829330","CDM","983","RC","14020","HCPCS","","","facility","both","","","","2119.48","2119.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Of Gallbladder","41829331","CDM","983","RC","47490","HCPCS","","","facility","both","","","","964.96","964.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reduction Of Rectal Prolapse","41829332","CDM","983","RC","45900","HCPCS","","","facility","both","","","","597.5","597.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Leg/Ankle Tum < 5Cm","41829333","CDM","983","RC","27615","HCPCS","","","facility","both","","","","2872.39","2872.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Paracentesis W/Imaging","41829336","CDM","983","RC","49083","HCPCS","","","facility","both","","","","926.64","926.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exploration/Repair Of Rectum","41829337","CDM","983","RC","45562","HCPCS","","","facility","both","","","","3144.88","3144.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surgery For Liver Lesion","41829338","CDM","983","RC","47300","HCPCS","","","facility","both","","","","3113.82","3113.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transcrv Abltj Utrn Fibrd Rf","41829339","CDM","983","RC","58580","HCPCS","","","facility","both","","","","10076.59","10076.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Chest Wall Tumor W/Ribs","41829340","CDM","983","RC","21601","HCPCS","","","facility","both","","","","3136.84","3136.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Embedded Ip Cath Exit-Site","41829341","CDM","983","RC","49436","HCPCS","","","facility","both","","","","1669.45","1669.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Rx Balo Cath Urtl Strx","41829342","CDM","983","RC","52284","HCPCS","","","facility","both","","","","8774.5","8774.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Tum 5 Cm Or Less","41829343","CDM","983","RC","49203","HCPCS","","","facility","both","","","","3216.9","3216.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Us Lmtd Jt/Fcl Evl Nvasc Xtr","41829344","CDM","983","RC","76882","HCPCS","","","facility","both","","","26","92.58","92.58","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Tis Trnfr S/A/L 10.1-30 Sqcm","41829345","CDM","983","RC","14021","HCPCS","","","facility","both","","","","2590.02","2590.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thoracostomy W/Rib Resection","41829346","CDM","983","RC","32035","HCPCS","","","facility","both","","","","2007.14","2007.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face-Mm B9+Marg 3.1-4 Cm","41829347","CDM","983","RC","11444","HCPCS","","","facility","both","","","","847.72","847.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Mouth Roof Fracture","41829348","CDM","983","RC","21423","HCPCS","","","facility","both","","","","2272.49","2272.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 30","41829349","CDM","983","RC","99402","HCPCS","","","facility","both","","","","152.13","152.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 45","41829350","CDM","983","RC","99403","HCPCS","","","facility","both","","","","227.15","227.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prev Med Cnsl Indiv Apprx 60","41829351","CDM","983","RC","99404","HCPCS","","","facility","both","","","","300.77","300.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Excessive Skin Arm","41829352","CDM","983","RC","15836","HCPCS","","","facility","both","","","","2286.65","2286.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Of Umbilicus","41829353","CDM","983","RC","49250","HCPCS","","","facility","both","","","","1644.29","1644.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosigmoidoscopy Fb","41829354","CDM","983","RC","45307","HCPCS","","","facility","both","","","","645.69","645.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41829355","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41829356","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Smpl Cn Npgt Prgrmg","41829357","CDM","983","RC","95976","HCPCS","","","facility","both","","","","119.96","119.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Cplx Cn Npgt Prgrmg","41829358","CDM","983","RC","95977","HCPCS","","","facility","both","","","","157.28","157.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excision Of Stomach Lesion","41829359","CDM","983","RC","43611","HCPCS","","","facility","both","","","","3284.67","3284.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Sternum Fracture","41829360","CDM","983","RC","21825","HCPCS","","","facility","both","","","","1579.79","1579.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"I&D Pilonidal Cyst Comp","41829361","CDM","983","RC","10081","HCPCS","","","facility","both","","","","1056.81","1056.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Prs Wnd Ther Ndme>50Sqcm","41829362","CDM","983","RC","97608","HCPCS","","","facility","both","","","","1177.86","1177.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Cervix","41829363","CDM","983","RC","59325","HCPCS","","","facility","both","","","","634.87","634.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cryoablate Prostate","41829364","CDM","983","RC","55873","HCPCS","","","facility","both","","","","18696.46","18696.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prcrd Drg 6Yr+ W/O Cgen Car","41829365","CDM","983","RC","33017","HCPCS","","","facility","both","","","","686.34","686.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","41829366","CDM","983","RC","11104","HCPCS","","","facility","both","","","","402.35","402.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Sep/Addl","41829367","CDM","983","RC","11105","HCPCS","","","facility","both","","","","192.32","192.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Mouth Lesion","41829368","CDM","983","RC","40808","HCPCS","","","facility","both","","","","512.12","512.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr Addl 30 Sq Cm","41829369","CDM","983","RC","14302","HCPCS","","","facility","both","","","","589.29","589.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abltj Mal Prst8 Tiss Hifu","41829370","CDM","983","RC","55880","HCPCS","","","facility","both","","","","2741.43","2741.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reset Dislocated Jaw","41829371","CDM","983","RC","21485","HCPCS","","","facility","both","","","","3088.4","3088.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reagent Strip/Blood Glucose","41829372","CDM","983","RC","82948","HCPCS","","","facility","both","","","","16.5","16.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sleep Study Attended","41829373","CDM","983","RC","95807","HCPCS","","","facility","both","","","","1341.97","1341.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rerepair Fem Hernia Blocked","41829374","CDM","983","RC","49557","HCPCS","","","facility","both","","","","1987.33","1987.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Abd Tum Over 5 Cm","41829375","CDM","983","RC","49204","HCPCS","","","facility","both","","","","4150.47","4150.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Diaphragm","41829376","CDM","983","RC","39545","HCPCS","","","facility","both","","","","2418.63","2418.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Supracrv Hyst W/T/O >250G","41829378","CDM","983","RC","58544","HCPCS","","","facility","both","","","","2464.45","2464.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Laparoscopy Px Spleen","41829379","CDM","983","RC","38129","HCPCS","","","facility","both","","","","2128.42","2128.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Of Rectal Abscess","41829380","CDM","983","RC","46045","HCPCS","","","facility","both","","","","1244.03","1244.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Anal Seton Oth Marker","41829381","CDM","983","RC","46030","HCPCS","","","facility","both","","","","781.8","781.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adrenalectmy Expl W/Exc Rp Tum","41829382","CDM","983","RC","60545","HCPCS","","","facility","both","","","","3319.65","3319.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Penis","41829383","CDM","983","RC","54440","HCPCS","","","facility","both","","","","4845.41","4845.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Sleeve Gastrectomy","41829384","CDM","983","RC","43775","HCPCS","","","facility","both","","","","2809.93","2809.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Skin Mm Sq Tis","41829385","CDM","983","RC","17999","HCPCS","","","facility","both","","","","2359.03","2359.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tis Trnfr E/N/E/L 10 Sq Cm/<","41829386","CDM","983","RC","14060","HCPCS","","","facility","both","","","","2251.58","2251.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Otolaryngologic Exam W/Anesth","41829387","CDM","983","RC","92502","HCPCS","","","facility","both","","","","272.05","272.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Blood Vessel Vein Grft","41829388","CDM","983","RC","35256","HCPCS","","","facility","both","","","","2514.73","2514.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompression Of Leg","41829389","CDM","983","RC","27893","HCPCS","","","facility","both","","","","1824.98","1824.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Flx Ins Xpns Urtl Scaf","41829390","CDM","983","RC","0941T","HCPCS","","","facility","both","","","","4501","4501","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Flx Rmv Rplc Urtl Scaf","41829391","CDM","983","RC","0942T","HCPCS","","","facility","both","","","","3333.52","3333.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Flx Rmvl Urtl Scaffold","41829392","CDM","983","RC","0943T","HCPCS","","","facility","both","","","","1433.91","1433.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Trurl Ablt Trnsdc Thr Us","41829393","CDM","983","RC","51721","HCPCS","","","facility","both","","","","1604.95","1604.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cysto Insj Dev Ischmc Rmdlg","41829394","CDM","983","RC","53865","HCPCS","","","facility","both","","","","9230.48","9230.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cathj Rmvl Dev Ischmc Rmdlg","41829395","CDM","983","RC","53866","HCPCS","","","facility","both","","","","405.73","405.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablt Trurl Prst8 Tis Thrm Us","41829396","CDM","983","RC","55881","HCPCS","","","facility","both","","","","27586.98","27586.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ablt Trurl Prst8 Tis Trnsdcr","41829397","CDM","983","RC","55882","HCPCS","","","facility","both","","","","28498.23","28498.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc/Dstr Ntra-Abd 5Cm/<","41829398","CDM","983","RC","49186","HCPCS","","","facility","both","","","","3437.23","3437.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dstr Ntra-Abd 5.1-10","41829399","CDM","983","RC","49187","HCPCS","","","facility","both","","","","4337.18","4337.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dst Ntra-Abd 10.1-20","41829400","CDM","983","RC","49188","HCPCS","","","facility","both","","","","5190.38","5190.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dst Ntra-Abd 20.1-30","41829401","CDM","983","RC","49189","HCPCS","","","facility","both","","","","6020.55","6020.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dstr Ntra-Abd >30Cm","41829402","CDM","983","RC","49190","HCPCS","","","facility","both","","","","7413.55","7413.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dstr Ntra-Abd 5 Cm/<","41829403","CDM","983","RC","49186","HCPCS","","","facility","both","","","","3437.23","3437.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dstr Ntra-Abd 5.1-10","41829404","CDM","983","RC","49187","HCPCS","","","facility","both","","","","4337.18","4337.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dst Ntra-Abd 10.1-20","41829405","CDM","983","RC","49188","HCPCS","","","facility","both","","","","5190.38","5190.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dst Ntra-Abd 20.1-30","41829406","CDM","983","RC","49189","HCPCS","","","facility","both","","","","6020.55","6020.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Exc Dstr Ntra-Abd >30Cm","41829407","CDM","983","RC","49190","HCPCS","","","facility","both","","","","7413.55","7413.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intro Ndl Icath Upr/Lxtr Art","41829408","CDM","983","RC","36140","HCPCS","","","facility","both","","","","1582.98","1582.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Uterus Lesion","41829409","CDM","983","RC","59100","HCPCS","","","facility","both","","","","2192.68","2192.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pericardiectomy Wo Cp Bypass","41829410","CDM","983","RC","33030","HCPCS","","","facility","both","","","","5565.97","5565.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Exc S/N/H/F/G Mal+Mrg 3.1-4","41829411","CDM","983","RC","11624","HCPCS","","","facility","both","","","","963.65","963.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drainage Of Hydrocele","41829412","CDM","983","RC","55000","HCPCS","","","facility","both","","","","340.68","340.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Enzymatic Debridement","41829413","CDM","983","RC","97602","HCPCS","","","facility","both","","","","70.93","70.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Cervix","41829414","CDM","983","RC","57720","HCPCS","","","facility","both","","","","923.4","923.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Vagina","41829415","CDM","983","RC","57200","HCPCS","","","facility","both","","","","923.93","923.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/ Micro","41830001","CDM","300","RC","81000","HCPCS","","","facility","both","","","","11","11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bronchospasm Pre Post","41830002","CDM","983","RC","94060","HCPCS","","","facility","both","","","","191.53","191.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41830010","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spirometry","41830012","CDM","460","RC","94010","HCPCS","","","facility","both","","","","103","103","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mnt, Group, Each 30 Minutes","41830017","CDM","983","RC","97804","HCPCS","","","facility","both","","","","51.42","51.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ua W/O Micro","41830019","CDM","300","RC","81002","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Pos Airway Pressure Cpap","41830020","CDM","983","RC","94660","HCPCS","","","facility","both","","","","195.99","195.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41830022","CDM","983","RC","99091","HCPCS","","","facility","both","","","","167.3","167.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Fingerstick","41830027","CDM","300","RC","82962","HCPCS","","","facility","both","","","","8","8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Nutrician Therapy Ea 15Mi","41830030","CDM","983","RC","97802","HCPCS","","","facility","both","","","","114.15","114.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reassess Nutrition Ther Ea 15M","41830031","CDM","983","RC","97803","HCPCS","","","facility","both","","","","99.09","99.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41830032","CDM","983","RC","G0108","HCPCS","","","facility","both","","","","166.42","166.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Grp","41830033","CDM","983","RC","G0109","HCPCS","","","facility","both","","","","46.66","46.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pregnancy Test","41830034","CDM","300","RC","81025","HCPCS","","","facility","both","","","","24","24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41830217","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41830225","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41830233","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41830241","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41830258","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41830266","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41830274","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41830282","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41830290","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41830316","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41830324","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41830332","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41830340","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna W/O Image","41830365","CDM","983","RC","10021","HCPCS","","","facility","both","","","","303.44","303.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"12 Lead Ekg Int Rep","41830373","CDM","983","RC","93010","HCPCS","","","facility","both","","","","24.41","24.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41830382","CDM","983","RC","90471","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Ea Addl S/C","41830399","CDM","510","RC","90472","HCPCS","","","facility","both","","","","163","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41830400","CDM","983","RC","90472","HCPCS","","","facility","both","","","","39.14","39.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mon Glucose Continuous <72 Hr","41830457","CDM","920","RC","95250","HCPCS","","","facility","both","","","","451","451","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Mon Glucose Contin <72 Hr","41830465","CDM","983","RC","95251","HCPCS","","","facility","both","","","","103.69","103.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intubation Et Emergent","41830550","CDM","983","RC","31500","HCPCS","","","facility","both","","","","400.91","400.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bronchoscope/Wash","41830551","CDM","983","RC","31622","HCPCS","","","facility","both","","","","750.44","750.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insertion Of Chest Tube","41830552","CDM","983","RC","32551","HCPCS","","","facility","both","","","","442.83","442.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Aspirate Pleura W/ Imaging","41830554","CDM","983","RC","32555","HCPCS","","","facility","both","","","","995.5","995.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Electrd/Pm Cath Sngl","41830555","CDM","983","RC","33210","HCPCS","","","facility","both","","","","457.45","457.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41830556","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Pf Ins Non-Tunnel Cv Cath 5 Yr","41830557","CDM","983","RC","36556","HCPCS","","","facility","both","","","","673.41","673.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arterial Cath - Mntr/Transfuse","41830558","CDM","983","RC","36620","HCPCS","","","facility","both","","","","125.63","125.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abdominal Paracentesis","41830559","CDM","983","RC","49082","HCPCS","","","facility","both","","","","655.77","655.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cpr","41830560","CDM","983","RC","92950","HCPCS","","","facility","both","","","","982.36","982.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41830561","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41830562","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41830563","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41830565","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41830566","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41830567","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","41830568","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","41830569","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","41830706","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","41830707","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","41830708","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","41830709","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41830710","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41830712","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41830713","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41830714","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41830715","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41830717","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41830718","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41830719","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41830720","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41830721","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41830722","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41830723","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41830724","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41830725","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41830726","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41830727","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41830728","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41830729","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41830730","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41830731","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41830733","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41830734","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41830735","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41830736","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41830737","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41830738","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41830739","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41830740","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41830741","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41830742","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41830743","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41830744","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41830746","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41830747","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41830748","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41830749","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"12 Lead Ekg Global","41830751","CDM","983","RC","93000","HCPCS","","","facility","both","","","","52.32","52.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Int Nutri Ther Ea","41830752","CDM","983","RC","97802","HCPCS","","","facility","both","","","95","114.15","114.15","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Reassess Nuti Ther","41830753","CDM","983","RC","97803","HCPCS","","","facility","both","","","95","99.09","99.09","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Cont Gluc Mntr Pt Prov Eqp","41830754","CDM","983","RC","95249","HCPCS","","","facility","both","","","","181.54","181.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Init Inpt Ed Teleconsult 30M","41830755","CDM","983","RC","G0425","HCPCS","","","facility","both","","","95","281.76","281.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 50M","41830756","CDM","983","RC","G0426","HCPCS","","","facility","both","","","95","383.76","383.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 70M","41830757","CDM","983","RC","G0427","HCPCS","","","facility","both","","","95","568.44","568.44","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","41830758","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41830759","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41830760","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","41830761","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41830762","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41830763","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41830764","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41830765","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41830766","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41830767","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Diab Self Mgmt Grp","41830768","CDM","983","RC","G0109","HCPCS","","","facility","both","","","95","46.66","46.66","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41830769","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Diab Self Mgmt Trn","41830770","CDM","983","RC","G0108","HCPCS","","","facility","both","","","95","166.42","166.42","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Hg A1C>Equal 7.0%<8.0%","41830771","CDM","983","RC","3051F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C>Equal 8.0%","41830772","CDM","983","RC","3052F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 5 10 Mins","41830773","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.7","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41830774","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.71","86.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41830775","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Care Mgmt 7 Day Disch","41830776","CDM","983","RC","99496","HCPCS","","","facility","both","","","","742.29","742.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Trans Care 7D/Dis","41830777","CDM","983","RC","99496","HCPCS","","","facility","both","","","95","742.29","742.29","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Trans Care Mgmt 14 Day Disc","41830778","CDM","983","RC","99495","HCPCS","","","facility","both","","","","562.59","562.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Trans Care 14D/Dis","41830779","CDM","983","RC","99495","HCPCS","","","facility","both","","","95","562.59","562.59","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Pf Ppps, Initial Visit","41830780","CDM","983","RC","G0438","HCPCS","","","facility","both","","","","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Ppps, Initial Visi","41830781","CDM","983","RC","G0438","HCPCS","","","facility","both","","","95","512.24","512.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Pf Ppps, Subseq Visit","41830782","CDM","983","RC","G0439","HCPCS","","","facility","both","","","","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Ppps, Subseq Visit","41830783","CDM","983","RC","G0439","HCPCS","","","facility","both","","","95","350.46","350.46","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Chron Care Mgmt Srvc 20 Min","41830784","CDM","983","RC","99490","HCPCS","","","facility","both","","","","123.45","123.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Chron Care W/O Pt Visit","41830785","CDM","983","RC","99487","HCPCS","","","facility","both","","","","280.57","280.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Chron Care Addl 30 Min","41830786","CDM","983","RC","99489","HCPCS","","","facility","both","","","","135.52","135.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Self Mgmnt Educ Train 1 Pt","41830787","CDM","983","RC","98960","HCPCS","","","facility","both","","","","82.52","82.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41830788","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Chronic Care Mgmt Svc Ea Addl","41830789","CDM","983","RC","99439","HCPCS","","","facility","both","","","","107.27","107.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medication Tx Init 15Mn New Pt","41830790","CDM","983","RC","99605","HCPCS","","","facility","both","","","","118","118","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medication Tx Init 15Mn Est Pt","41830791","CDM","983","RC","99606","HCPCS","","","facility","both","","","","94.95","94.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medication Tx Each Add 15Min","41830792","CDM","983","RC","99607","HCPCS","","","facility","both","","","","75.68","75.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Edu Train Self Mgt Nonphys 2 4","41830793","CDM","983","RC","98961","HCPCS","","","facility","both","","","","113.07","113.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Edu Train Self Mgt Nonphys 5 8","41830794","CDM","983","RC","98962","HCPCS","","","facility","both","","","","133.36","133.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/ Retinopathy","41830796","CDM","983","RC","2022F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilat Retinal W/O Retinopathy","41830797","CDM","983","RC","2023F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diabetes Self Mgmt Trning Ind","41850013","CDM","983","RC","G0108","HCPCS","","","facility","both","","","","166.42","166.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Us Fine Needle Bx/Aspir","41850014","CDM","983","RC","43238","HCPCS","","","facility","both","","","","681.88","681.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Eye Exam W/Photo","41850015","CDM","983","RC","92250","HCPCS","","","facility","both","","","","141.88","141.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41850017","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Pancreas","41850026","CDM","983","RC","48999","HCPCS","","","facility","both","","","","4734.7","4734.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41850033","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Esoph Scope W/Submucous Inj","41850035","CDM","983","RC","43201","HCPCS","","","facility","both","","","","769.2","769.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Esophagoscopy Flex Biopsy","41850036","CDM","983","RC","43202","HCPCS","","","facility","both","","","","1098.06","1098.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Esophagoscopy Control Bleed","41850037","CDM","983","RC","43227","HCPCS","","","facility","both","","","","2027.97","2027.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Diagnostic Brush Wash","41850038","CDM","983","RC","43235","HCPCS","","","facility","both","","","","890.23","890.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Uppr Gi Scope W/Submuc Inj","41850039","CDM","983","RC","43236","HCPCS","","","facility","both","","","","1201.91","1201.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Biopsy Single/Multiple","41850040","CDM","983","RC","43239","HCPCS","","","facility","both","","","","1198.8","1198.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Injection Varices","41850042","CDM","983","RC","43243","HCPCS","","","facility","both","","","","694.61","694.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Varices Ligation","41850043","CDM","983","RC","43244","HCPCS","","","facility","both","","","","720.12","720.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Dilate Stricture","41850044","CDM","983","RC","43245","HCPCS","","","facility","both","","","","1910.05","1910.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Place Gastrostomy Tube","41850045","CDM","983","RC","43246","HCPCS","","","facility","both","","","","581.61","581.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Guide Wire Insertion","41850047","CDM","983","RC","43248","HCPCS","","","facility","both","","","","1237.7","1237.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esoph Egd Dilation <30 Mm","41850048","CDM","983","RC","43249","HCPCS","","","facility","both","","","","3627.25","3627.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Cautery Tumor Polyp","41850049","CDM","983","RC","43250","HCPCS","","","facility","both","","","","1380.35","1380.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Remove Lesion Snare","41850050","CDM","983","RC","43251","HCPCS","","","facility","both","","","","1519.85","1519.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Control Bleeding Any","41850051","CDM","983","RC","43255","HCPCS","","","facility","both","","","","2128.42","2128.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Us Exam Duodenum/Jejunu","41850053","CDM","983","RC","43259","HCPCS","","","facility","both","","","","664.81","664.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp W/Specimen Collection","41850054","CDM","983","RC","43260","HCPCS","","","facility","both","","","","945.49","945.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp W Bx Single/Multiple","41850055","CDM","983","RC","43261","HCPCS","","","facility","both","","","","991.55","991.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp W Sphincter/Papillotom","41850056","CDM","983","RC","43262","HCPCS","","","facility","both","","","","1046.61","1046.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp Sphincter Pressure Mea","41850057","CDM","983","RC","43263","HCPCS","","","facility","both","","","","1046.61","1046.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41850058","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp Duct Stent Placement","41850059","CDM","983","RC","43274","HCPCS","","","facility","both","","","","1354.27","1354.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp Remove Forgn Body Duct","41850060","CDM","983","RC","43275","HCPCS","","","facility","both","","","","1101.67","1101.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp Ea Duct/Ampulla Dilate","41850061","CDM","983","RC","43277","HCPCS","","","facility","both","","","","1107.99","1107.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Si Endo W Bleed Cntrl","41850062","CDM","983","RC","44366","HCPCS","","","facility","both","","","","705.01","705.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ileoscopy Thru Stoma W Bx","41850063","CDM","983","RC","44382","HCPCS","","","facility","both","","","","937.71","937.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Endoscopy Of Bowel Pouch","41850064","CDM","983","RC","44385","HCPCS","","","facility","both","","","","645.69","645.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy Thru Stoma Spx","41850065","CDM","983","RC","44388","HCPCS","","","facility","both","","","","951.72","951.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Sigmoidoscope W/Submuc Inj","41850067","CDM","983","RC","45335","HCPCS","","","facility","both","","","","873.54","873.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Colonoscopy","41850069","CDM","983","RC","45378","HCPCS","","","facility","both","","","","1027.04","1027.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colonoscopy Submucous Njx","41850071","CDM","983","RC","45381","HCPCS","","","facility","both","","","","1333.51","1333.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Control Bleed","41850072","CDM","983","RC","45382","HCPCS","","","facility","both","","","","2255.77","2255.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41850074","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colonoscopy W/Endoscope Us","41850075","CDM","983","RC","45391","HCPCS","","","facility","both","","","","755.51","755.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf G-Esoph Reflux W Mucosal Ph","41850076","CDM","983","RC","91035","HCPCS","","","facility","both","","","","1594.44","1594.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41850077","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41850078","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41850079","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41850080","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Prostate Ca Screening Digi","41850086","CDM","983","RC","G0102","HCPCS","","","facility","both","","","","72.15","72.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Scrn Colonoscopy On Hi Risk","41850087","CDM","983","RC","G0105","HCPCS","","","facility","both","","","","1026.6","1026.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scrn Colonoscopy-Not Hi Risk","41850088","CDM","983","RC","G0121","HCPCS","","","facility","both","","","","1027.51","1027.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Egd Us Fine Needle Bx/Aspir","41850089","CDM","983","RC","43242","HCPCS","","","facility","both","","","","771.55","771.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41850090","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Ercp Remove Duct Calculi","41850092","CDM","983","RC","43264","HCPCS","","","facility","both","","","","1065.9","1065.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy Thru Stoma W Bx","41850093","CDM","983","RC","44389","HCPCS","","","facility","both","","","","1274.45","1274.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endo Cath - Bile Ducts","41850094","CDM","983","RC","74328","HCPCS","","","facility","both","","","26","103.98","103.98","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Endo Cath - Pancr Duct","41850095","CDM","983","RC","74329","HCPCS","","","facility","both","","","26","103.98","103.98","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Endo Cath Bil Pancr D","41850096","CDM","983","RC","74330","HCPCS","","","facility","both","","","26","133.02","133.02","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Colonoscopy W/Balloon Dilat","41850097","CDM","983","RC","45386","HCPCS","","","facility","both","","","","1967.71","1967.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W Rem T/P/Les By","41850109","CDM","983","RC","45338","HCPCS","","","facility","both","","","","901.77","901.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Ultrasound","41850110","CDM","983","RC","45341","HCPCS","","","facility","both","","","","364.9","364.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Resection","41850111","CDM","983","RC","45349","HCPCS","","","facility","both","","","","582.93","582.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41850132","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41850157","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41850173","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41850199","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41850231","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41850256","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41850272","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41850298","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41850308","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diagnostic Sigmoidoscopy","41850355","CDM","983","RC","45330","HCPCS","","","facility","both","","","","568.9","568.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sigmoidoscopy W/ Bx","41850363","CDM","510","RC","45331","HCPCS","","","facility","both","","","","1132","1132","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy Flex W Bx","41850371","CDM","983","RC","45331","HCPCS","","","facility","both","","","","901.33","901.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sigmoidoscopy W/ Caut","41850389","CDM","510","RC","45333","HCPCS","","","facility","both","","","","1856","1856","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/ Caut","41850397","CDM","983","RC","45333","HCPCS","","","facility","both","","","","1016.35","1016.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Phlebotomy","41850405","CDM","510","RC","99195","HCPCS","","","facility","both","","","","130","130","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phlebotomy","41850413","CDM","983","RC","99195","HCPCS","","","facility","both","","","","335.63","335.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagus Motility Study","41850447","CDM","510","RC","91010","HCPCS","","","facility","both","","","","754","754","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagus Motility Study","41850454","CDM","983","RC","91010","HCPCS","","","facility","both","","","","648.02","648.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagus Motility W/ Acid Per","41850470","CDM","983","RC","91013","HCPCS","","","facility","both","","","","82.69","82.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastric Intubation For Smear","41850496","CDM","983","RC","43754","HCPCS","","","facility","both","","","","602.21","602.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Breath Hydrogen Test","41850520","CDM","510","RC","91065","HCPCS","","","facility","both","","","","334","334","","","","","","","","","","","","","Gross Charge Type: Standard"
"Breath Hydrogen/Methane Test","41850538","CDM","983","RC","91065","HCPCS","","","facility","both","","","","264.09","264.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Gastric Intubation Tx","41850546","CDM","510","RC","43753","HCPCS","","","facility","both","","","","115","115","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Gastro Intub W/Asp","41850553","CDM","983","RC","43753","HCPCS","","","facility","both","","","","61.72","61.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Anorectal Manometry","41850561","CDM","510","RC","91122","HCPCS","","","facility","both","","","","615","615","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anorectal Manometry","41850579","CDM","983","RC","91122","HCPCS","","","facility","both","","","","806.41","806.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41850604","CDM","983","RC","90471","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Ea Addl S/C","41850611","CDM","510","RC","90472","HCPCS","","","facility","both","","","","163","163","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Adm Ea Addl S/C","41850612","CDM","983","RC","90472","HCPCS","","","facility","both","","","","39.14","39.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Occult Blood Feces Single Det","41850629","CDM","300","RC","82270","HCPCS","","","facility","both","","","","10","10","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gi Tract Capsule Endoscopy","41850637","CDM","983","RC","91110","HCPCS","","","facility","both","","","","2849.39","2849.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anoscopy Diagnostic","41850703","CDM","983","RC","46600","HCPCS","","","facility","both","","","","332.9","332.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Anoscopy Diagnostic","41850711","CDM","510","RC","46600","HCPCS","","","facility","both","","","","144","144","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destroy Internal Hemorrhoids","41850729","CDM","983","RC","46930","HCPCS","","","facility","both","","","","681.07","681.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Skin At Fx Site","41850730","CDM","983","RC","11010","HCPCS","","","facility","both","","","","1479.13","1479.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mediastinotomy Transthoracic","41850731","CDM","983","RC","39010","HCPCS","","","facility","both","","","","2224.87","2224.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nasal /Orogastric W/Tube Plmt","41850732","CDM","983","RC","43752","HCPCS","","","facility","both","","","","117.6","117.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Enterolysis","41850733","CDM","983","RC","44180","HCPCS","","","facility","both","","","","2624.54","2624.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove By Ligat Int Hem 2+ Grp","41850734","CDM","983","RC","46946","HCPCS","","","facility","both","","","","1149.17","1149.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Ing Hernia Init Reduce 0.5","41850735","CDM","983","RC","49500","HCPCS","","","facility","both","","","","1206.42","1206.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ercp W/Specimen Collection","41850736","CDM","983","RC","43260","HCPCS","","","facility","both","","","","945.49","945.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Destroy Int Hemorrhoid","41850737","CDM","510","RC","46930","HCPCS","","","facility","both","","","","1175","1175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lap Ileo/Jejuno-Stomy","41850738","CDM","983","RC","44187","HCPCS","","","facility","both","","","","3199.88","3199.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Endoscopic Stent Place","41850739","CDM","983","RC","43266","HCPCS","","","facility","both","","","","634.94","634.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ercp Stent Exchange W /Dilate","41850740","CDM","983","RC","43276","HCPCS","","","facility","both","","","","1409.86","1409.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ercp Lithotripsy Calculi","41850741","CDM","983","RC","43265","HCPCS","","","facility","both","","","","1268.53","1268.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ercp Lesion Ablate W/Dilate","41850742","CDM","983","RC","43278","HCPCS","","","facility","both","","","","1268.01","1268.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Lesion Removal","41850743","CDM","983","RC","45384","HCPCS","","","facility","both","","","","1489.79","1489.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Resection","41850744","CDM","983","RC","45390","HCPCS","","","facility","both","","","","974.26","974.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41850747","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","41850748","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit I","41850749","CDM","983","RC","99281","HCPCS","","","facility","both","","","","62.85","62.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Ii","41850750","CDM","983","RC","99282","HCPCS","","","facility","both","","","","121.11","121.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iii","41850751","CDM","983","RC","99283","HCPCS","","","facility","both","","","","180.92","180.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","41850752","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","41850753","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Remove Foreign Body","41850754","CDM","983","RC","43247","HCPCS","","","facility","both","","","","1169.53","1169.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopic Us Exam Esoph","41850755","CDM","983","RC","43237","HCPCS","","","facility","both","","","","574.69","574.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","41850756","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","41850757","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Tube/Cath Insertion","41850758","CDM","983","RC","43241","HCPCS","","","facility","both","","","","416.43","416.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Fb Removal","41850759","CDM","983","RC","45379","HCPCS","","","facility","both","","","","1324.53","1324.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscopy Lesion Ablate","41850760","CDM","983","RC","43229","HCPCS","","","facility","both","","","","2262.47","2262.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Colonoscopy And Biopsy","41850761","CDM","983","RC","45380","HCPCS","","","facility","both","","","","1344.25","1344.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Ablation","41850763","CDM","983","RC","45388","HCPCS","","","facility","both","","","","9747.1","9747.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Lesion Ablation","41850764","CDM","983","RC","43270","HCPCS","","","facility","both","","","","2313.61","2313.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41850765","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy For Bleeding","41850766","CDM","983","RC","45334","HCPCS","","","facility","both","","","","1735.45","1735.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Plcmt Stent","41850767","CDM","983","RC","45347","HCPCS","","","facility","both","","","","452.02","452.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy Stoma W Rem Snare","41850768","CDM","983","RC","44394","HCPCS","","","facility","both","","","","1324.89","1324.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Us Transmural Injxn/Mark","41850769","CDM","983","RC","43253","HCPCS","","","facility","both","","","","772.48","772.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscopy Flexible Brush","41850770","CDM","983","RC","43200","HCPCS","","","facility","both","","","","777.55","777.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41850771","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41850772","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41850773","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41850774","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41850776","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41850777","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41850778","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41850779","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41850780","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41850781","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41850782","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41850783","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41850784","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41850785","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41850786","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41850787","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41850788","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41850789","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41850790","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosig Rigid W Bx Sgl Multi","41850791","CDM","983","RC","45305","HCPCS","","","facility","both","","","","514.9","514.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laps Esophgl Sphnctr Agmnt","41850792","CDM","983","RC","43284","HCPCS","","","facility","both","","","","1871.22","1871.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Esophgl Sphnctr Dev","41850793","CDM","983","RC","43285","HCPCS","","","facility","both","","","","1924.89","1924.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41850794","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Sigmoidoscopy Decompress","41850795","CDM","983","RC","45337","HCPCS","","","facility","both","","","","335.66","335.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Endo Mucosal Resection","41850796","CDM","983","RC","43254","HCPCS","","","facility","both","","","","792.72","792.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp <5 Yrs","41850797","CDM","983","RC","99151","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","41850798","CDM","983","RC","99152","HCPCS","","","facility","both","","","","164.03","164.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea","41850799","CDM","983","RC","99153","HCPCS","","","facility","both","","","","35.04","35.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp <5 Yrs","41850800","CDM","983","RC","99155","HCPCS","","","facility","both","","","","235.58","235.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp 5/>Yrs","41850801","CDM","983","RC","99156","HCPCS","","","facility","both","","","","220.09","220.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Ea","41850802","CDM","983","RC","99157","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Injection","41850803","CDM","983","RC","44404","HCPCS","","","facility","both","","","","1268.01","1268.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd W/Transmural Drain Cyst","41850804","CDM","983","RC","43240","HCPCS","","","facility","both","","","","1148.11","1148.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Endoscopic Fnb","41850805","CDM","983","RC","45392","HCPCS","","","facility","both","","","","890.87","890.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41850808","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41850809","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41850810","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41850811","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41850812","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41850813","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41850814","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41850815","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41850816","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41850817","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41850818","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41850819","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41850821","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41850822","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41850823","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41850824","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Colonoscopy W/Stent Plcmt","41850825","CDM","983","RC","45389","HCPCS","","","facility","both","","","","847.28","847.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Ablation","41850826","CDM","983","RC","45346","HCPCS","","","facility","both","","","","9256.46","9256.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sedat Endo Service >5Yrs","41850827","CDM","983","RC","G0500","HCPCS","","","facility","both","","","","187.39","187.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopy Bowel Pouch/Biop","41850828","CDM","983","RC","44386","HCPCS","","","facility","both","","","","975","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sml Intestestine Endo W/Bx","41850829","CDM","983","RC","44361","HCPCS","","","facility","both","","","","466.52","466.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Decompressn","41850830","CDM","983","RC","45393","HCPCS","","","facility","both","","","","733.72","733.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligation Of Hemorrhoid(S)","41850831","CDM","983","RC","46221","HCPCS","","","facility","both","","","","863.57","863.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","41850833","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","41850834","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","41850835","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Band Ligation","41850836","CDM","983","RC","45398","HCPCS","","","facility","both","","","","2537.46","2537.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sig W/Tndsc Balloon Dilation","41850839","CDM","983","RC","45340","HCPCS","","","facility","both","","","","1504.19","1504.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Introd Long Gi Tube","41850840","CDM","983","RC","44500","HCPCS","","","facility","both","","","","56.63","56.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoking 3-10 Min","41850841","CDM","983","RC","99406","HCPCS","","","facility","both","","","","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Stomach","41850842","CDM","983","RC","43999","HCPCS","","","facility","both","","","","1071.49","1071.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Pancreas","41850843","CDM","983","RC","48999","HCPCS","","","facility","both","","","","7906.9","7906.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate For Stricture/Obstr","41850844","CDM","983","RC","74360","HCPCS","","","facility","both","","","","80.73","80.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Us Guide Bx","41850845","CDM","983","RC","45342","HCPCS","","","facility","both","","","","498.91","498.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep G Tube No Tract Revision","41850847","CDM","983","RC","43762","HCPCS","","","facility","both","","","","745.38","745.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep G Tube W Tract Revision","41850848","CDM","983","RC","43763","HCPCS","","","facility","both","","","","1102.92","1102.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscp Rig Trnso Biopsy","41850849","CDM","983","RC","43193","HCPCS","","","facility","both","","","","492.86","492.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Endoscopic Pancreatoscopy","41850850","CDM","983","RC","43273","HCPCS","","","facility","both","","","","349.79","349.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscopy Balloon <30Mm","41850851","CDM","983","RC","43220","HCPCS","","","facility","both","","","","3374.98","3374.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gastroesoph Reflux W/Nasal Ph","41850852","CDM","983","RC","91034","HCPCS","","","facility","both","","","","620.49","620.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Behav Chng Smoke>10 Mins","41850853","CDM","983","RC","99407","HCPCS","","","facility","both","","","","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esoph Imped Funct Test > 1H","41850854","CDM","983","RC","91038","HCPCS","","","facility","both","","","","1458.56","1458.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abd Paracentesis W/Imaging","41850855","CDM","983","RC","49083","HCPCS","","","facility","both","","","","967.17","967.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Stomach","41850856","CDM","983","RC","43999","HCPCS","","","facility","both","","","","1996.63","1996.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Stomach","41850857","CDM","983","RC","43999","HCPCS","","","facility","both","","","","2088.07","2088.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41850858","CDM","983","RC","99091","HCPCS","","","facility","both","","","","167.3","167.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mntr Physiol Param Setup","41850859","CDM","983","RC","99453","HCPCS","","","facility","both","","","","61.31","61.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proctosigmoidoscpy Rigid Dx","41850860","CDM","983","RC","45300","HCPCS","","","facility","both","","","","395.52","395.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Lesion Removal","41850861","CDM","983","RC","45385","HCPCS","","","facility","both","","","","1379.91","1379.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Small Bowel Endoscopy Brsh/Wsh","41850862","CDM","983","RC","44380","HCPCS","","","facility","both","","","","596.01","596.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Hrhc Transanal Dartlztn 2+","41850863","CDM","983","RC","46948","HCPCS","","","facility","both","","","","1322.18","1322.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscopy W/Us Needle Bx","41850864","CDM","983","RC","43232","HCPCS","","","facility","both","","","","586.89","586.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Px Small Intestine","41850865","CDM","983","RC","44799","HCPCS","","","facility","both","","","","1164.67","1164.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Convert Perc Gt To Jt","41850866","CDM","983","RC","44373","HCPCS","","","facility","both","","","","549.33","549.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Init Hosp Care I","41850867","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 30M","41850868","CDM","983","RC","G0425","HCPCS","","","facility","both","","","95","281.76","281.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 50M","41850869","CDM","983","RC","G0426","HCPCS","","","facility","both","","","95","383.76","383.76","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Init Inpt Ed Teleconsult 70M","41850870","CDM","983","RC","G0427","HCPCS","","","facility","both","","","95","568.44","568.44","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","41850871","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41850872","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41850873","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","41850874","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41850875","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41850876","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41850877","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41850878","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41850879","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41850880","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41850881","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Endoscopy Small Bowel","41850882","CDM","983","RC","44360","HCPCS","","","facility","both","","","","413.96","413.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy For Bleeding","41850883","CDM","983","RC","44391","HCPCS","","","facility","both","","","","2112.89","2112.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 5 10 Mins","41850884","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.7","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41850885","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.71","86.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41850886","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Egd Varices Ligation","41850888","CDM","983","RC","43244","HCPCS","","","facility","both","","","","720.12","720.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enteroscopy Sm Int W Stent","41850889","CDM","983","RC","44379","HCPCS","","","facility","both","","","","1173.82","1173.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect/Debride Pancreas","41850890","CDM","983","RC","48105","HCPCS","","","facility","both","","","","7906.9","7906.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Colon","41850891","CDM","983","RC","45399","HCPCS","","","facility","both","","","","1623.54","1623.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sigmoidoscopy W/Fb Removal","41850892","CDM","983","RC","45332","HCPCS","","","facility","both","","","","820.01","820.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41850893","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gi Wireless Capsule Measure","41850894","CDM","983","RC","91112","HCPCS","","","facility","both","","","","5356.52","5356.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Dilation","41850895","CDM","983","RC","44405","HCPCS","","","facility","both","","","","1825.6","1825.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Colonoscopy W/Stent Plcmt","41850896","CDM","983","RC","44402","HCPCS","","","facility","both","","","","726.15","726.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Gi Endoscopic Us S I","41850897","CDM","983","RC","76975","HCPCS","","","facility","both","","","","116.34","116.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enteroscopy 2P Ileum Cntr Bld","41850903","CDM","983","RC","44378","HCPCS","","","facility","both","","","","1066.9","1066.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ca Screen Flexi Sigmoidscope","41850904","CDM","983","RC","G0104","HCPCS","","","facility","both","","","","593.49","593.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Biliary Drain Cath W/Img","41850905","CDM","983","RC","47533","HCPCS","","","facility","both","","","","3981.52","3981.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Enteroscopy 2Nd Prtn Plmt Tube","41850907","CDM","983","RC","44372","HCPCS","","","facility","both","","","","659.56","659.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plmt Ureteral Stent Prq","41850908","CDM","983","RC","50693","HCPCS","","","facility","both","","","","3258.56","3258.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Biopsy Pancreas","41850909","CDM","983","RC","48102","HCPCS","","","facility","both","","","","621.24","621.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esophagoscopy Flexible Transor","41850910","CDM","983","RC","43231","HCPCS","","","facility","both","","","","427.74","427.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prssr Trtmnt Esphgs","41850911","CDM","983","RC","43460","HCPCS","","","facility","both","","","","587.05","587.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","41850912","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Esoph Endoscopy Dilation","41850914","CDM","983","RC","43226","HCPCS","","","facility","both","","","","1220.37","1220.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Service W/O Contact","41850915","CDM","983","RC","99358","HCPCS","","","facility","both","","","","323.32","323.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Small Bowel Endoscopy Br/Wa","41850916","CDM","983","RC","44381","HCPCS","","","facility","both","","","","3252.95","3252.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dilate Esophagus 1/Mult Pass","41850917","CDM","983","RC","43450","HCPCS","","","facility","both","","","","587.13","587.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sgmdsc W/Band Ligation","41850920","CDM","983","RC","45350","HCPCS","","","facility","both","","","","2154.89","2154.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41850921","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","41870101","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","41870102","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","41870103","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","41870104","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","41870105","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","41870106","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","41870107","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","41870108","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","41870109","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","41870111","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","41870112","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","41870113","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","41870114","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","41870115","CDM","983","RC","10160","HCPCS","","","facility","both","","","","406.03","406.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Reprgm Csf Shunt","41870116","CDM","983","RC","62252","HCPCS","","","facility","both","","","","241.31","241.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Puncture Shunt Tubing/Reser","41870118","CDM","983","RC","61070","HCPCS","","","facility","both","","","","165.21","165.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Evac Hematom","41870119","CDM","983","RC","61312","HCPCS","","","facility","both","","","","5720.26","5720.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx S Wnd Dehisc Smpl","41870120","CDM","983","RC","12020","HCPCS","","","facility","both","","","","917.11","917.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Of Spinal Lamina Sgl Lumb","41870121","CDM","983","RC","63047","HCPCS","","","facility","both","","","","3159.16","3159.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Stim Electric Bone Noninvas","41870122","CDM","983","RC","20974","HCPCS","","","facility","both","","","","245.91","245.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Spinal Lamina Add On","41870123","CDM","983","RC","63048","HCPCS","","","facility","both","","","","586.69","586.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wc P S Pr4 6 Pages","41870127","CDM","999","RC","","","","","facility","both","","","","394","394","","","","","","","","","","","","","Gross Charge Type: Standard"
"Consultaton Referred Xr","41870128","CDM","983","RC","76140","HCPCS","","","facility","both","","","","63.37","63.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc/Repl Spine Nstim Pg/Rcvr","41870130","CDM","983","RC","63685","HCPCS","","","facility","both","","","","1055.18","1055.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Evac Hemat Infrat","41870132","CDM","983","RC","61314","HCPCS","","","facility","both","","","","5066.83","5066.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Create Shunt Ventriculo Perit","41870133","CDM","983","RC","62223","HCPCS","","","facility","both","","","","2940.44","2940.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Low Back Disk Surgery","41870134","CDM","983","RC","63030","HCPCS","","","facility","both","","","","2795.27","2795.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Operating Microscope Add-On","41870135","CDM","983","RC","69990","HCPCS","","","facility","both","","","","588.73","588.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Spine Fusion Combined","41870137","CDM","983","RC","22633","HCPCS","","","facility","both","","","","5253.41","5253.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Spine Fixation Device P","41870138","CDM","983","RC","22840","HCPCS","","","facility","both","","","","2116.58","2116.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scan Proc Spinal","41870140","CDM","983","RC","61783","HCPCS","","","facility","both","","","","637.67","637.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","41870141","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","41870142","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","41870143","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","41870144","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Evac Hematom Intr","41870146","CDM","983","RC","61313","HCPCS","","","facility","both","","","","5495.8","5495.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Spine Fixation Device","41870148","CDM","983","RC","22840","HCPCS","","","facility","both","","","","2116.58","2116.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","41870150","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hypophys Or Exc Pituit Tumor","41870151","CDM","983","RC","61548","HCPCS","","","facility","both","","","","4375.9","4375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Spine Fusion Anterior","41870152","CDM","983","RC","22558","HCPCS","","","facility","both","","","","4376.32","4376.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Spine Fixatn Device 2-3 Se","41870153","CDM","983","RC","22845","HCPCS","","","facility","both","","","","2019.14","2019.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis P Pl 1L Below C2","41870154","CDM","983","RC","22600","HCPCS","","","facility","both","","","","3690.68","3690.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Spine Fusion Posterior","41870155","CDM","983","RC","22630","HCPCS","","","facility","both","","","","4462.61","4462.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Spine Fixation Device 3","41870156","CDM","983","RC","22842","HCPCS","","","facility","both","","","","2124.01","2124.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis Posterior Ea Addt","41870157","CDM","983","RC","22614","HCPCS","","","facility","both","","","","1089.12","1089.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis Pt C1-C2","41870158","CDM","983","RC","22595","HCPCS","","","facility","both","","","","4267.99","4267.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Neck Spine Fracture 1 Fx","41870159","CDM","983","RC","22326","HCPCS","","","facility","both","","","","4251.84","4251.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy W Exc Intrasp Les","41870160","CDM","983","RC","63267","HCPCS","","","facility","both","","","","3882.28","3882.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Bx Asp Or Exc For Intracran","41870161","CDM","983","RC","61750","HCPCS","","","facility","both","","","","3906.41","3906.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lumbar Spine Fusion","41870164","CDM","983","RC","22612","HCPCS","","","facility","both","","","","4544.8","4544.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hypophys Or Exc Pituit Tumor T","41870165","CDM","983","RC","61548","HCPCS","","","facility","both","","","","4375.9","4375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp Bone Algrft Struct Add-On","41870169","CDM","983","RC","20931","HCPCS","","","facility","both","","","","307.35","307.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranioplasty Skull Defct 5 Cm","41870170","CDM","983","RC","62141","HCPCS","","","facility","both","","","","3207.23","3207.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole W Dr Hematom Extrad/","41870171","CDM","983","RC","61154","HCPCS","","","facility","both","","","","3567.08","3567.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Bf Exc Brain Tumo","41870172","CDM","983","RC","61510","HCPCS","","","facility","both","","","","6089.85","6089.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scan Proc Cranial Intra","41870173","CDM","983","RC","61781","HCPCS","","","facility","both","","","","637","637","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remvl Of Spinal Lamina Cerv 1","41870174","CDM","983","RC","63001","HCPCS","","","facility","both","","","","3471.03","3471.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remvl Of Spinal Lamina Thorac","41870175","CDM","983","RC","63003","HCPCS","","","facility","both","","","","3482.24","3482.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Create Shunt Subarach Subdur","41870176","CDM","983","RC","62192","HCPCS","","","facility","both","","","","2756.33","2756.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drill Skull For Implantation","41870177","CDM","983","RC","61107","HCPCS","","","facility","both","","","","848.57","848.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroendoscopy Add-On","41870178","CDM","983","RC","62160","HCPCS","","","facility","both","","","","510.9","510.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","41870179","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","41870180","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","41870181","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","41870182","CDM","983","RC","10140","HCPCS","","","facility","both","","","","530.14","530.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx <=50Sqcm","41870183","CDM","983","RC","97605","HCPCS","","","facility","both","","","","135.24","135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","41870184","CDM","983","RC","11042","HCPCS","","","facility","both","","","","396.45","396.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia 20 Sq Cm/<","41870185","CDM","983","RC","11043","HCPCS","","","facility","both","","","","706.07","706.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl/Repl Pr Pump For Infusion","41870186","CDM","983","RC","62362","HCPCS","","","facility","both","","","","1115.23","1115.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Spine Infus Pump","41870187","CDM","983","RC","62367","HCPCS","","","facility","both","","","","95.53","95.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Sp Inf Pump W/Reprog","41870188","CDM","983","RC","62368","HCPCS","","","facility","both","","","","133.57","133.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Create Shunt-Lumb/Subarach/Per","41870192","CDM","983","RC","63740","HCPCS","","","facility","both","","","","2759.34","2759.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","41870193","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thorax Spine Fusion","41870194","CDM","983","RC","22610","HCPCS","","","facility","both","","","","3642.29","3642.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Spine Fix Device 7-12 Se","41870195","CDM","983","RC","22843","HCPCS","","","facility","both","","","","2272.62","2272.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spinal Lamina Sgl Cervi","41870196","CDM","983","RC","63045","HCPCS","","","facility","both","","","","3640.21","3640.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spinal Lamina Sgl Thora","41870197","CDM","983","RC","63046","HCPCS","","","facility","both","","","","3493.73","3493.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neck Spine Fuse Remov Bel C2","41870198","CDM","983","RC","22551","HCPCS","","","facility","both","","","","4815.49","4815.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spine Fuse Remv Cer Belw C2 Ea","41870199","CDM","983","RC","22552","HCPCS","","","facility","both","","","","1100.59","1100.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spine Fusion Wo Decomprs Cerv","41870200","CDM","983","RC","22554","HCPCS","","","facility","both","","","","3585.69","3585.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insrt Spine Fix Device 4-7 Seg","41870201","CDM","983","RC","22846","HCPCS","","","facility","both","","","","2098.88","2098.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iii","41870202","CDM","983","RC","99283","HCPCS","","","facility","both","","","","180.92","180.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pierce Skull Implant Device","41870203","CDM","983","RC","61210","HCPCS","","","facility","both","","","","994.36","994.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl/Revise Epid Cath For Pain","41870205","CDM","983","RC","62350","HCPCS","","","facility","both","","","","1159.83","1159.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Bf Exc Meningioma","41870206","CDM","983","RC","61512","HCPCS","","","facility","both","","","","7035.49","7035.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroplasty Median Nrve C T","41870207","CDM","983","RC","64721","HCPCS","","","facility","both","","","","1323.76","1323.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise/Remove Neuroelectrode","41870208","CDM","983","RC","64585","HCPCS","","","facility","both","","","","777.37","777.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spine Eltrd Perq Aray","41870209","CDM","983","RC","63661","HCPCS","","","facility","both","","","","2019.26","2019.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","41870210","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remvl Bone Flap/ Prosthetic Pl","41870211","CDM","983","RC","62142","HCPCS","","","facility","both","","","","2501.75","2501.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vert Corpectomy Cerv Sgl Seg","41870212","CDM","983","RC","63081","HCPCS","","","facility","both","","","","4970.73","4970.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Additional Spinal Fusion","41870213","CDM","983","RC","22585","HCPCS","","","facility","both","","","","913.37","913.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace/Irrigate Ventric Cath","41870214","CDM","983","RC","62225","HCPCS","","","facility","both","","","","1517.45","1517.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Sq Rsvr/Pump Prev Epid Inf","41870215","CDM","983","RC","62365","HCPCS","","","facility","both","","","","865.05","865.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Scan Proc Cranial Extra","41870216","CDM","983","RC","61782","HCPCS","","","facility","both","","","","498.8","498.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Disk Surgery Add-On","41870217","CDM","983","RC","63035","HCPCS","","","facility","both","","","","531.4","531.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Impl Deep","41870218","CDM","983","RC","20680","HCPCS","","","facility","both","","","","1903.1","1903.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroscope Exam =< 1 Hr","41870219","CDM","983","RC","76000","HCPCS","","","facility","both","","","","131.72","131.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Vertebr Fx/Disloc W Cast","41870220","CDM","983","RC","22315","HCPCS","","","facility","both","","","","2640.97","2640.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pexc Vb B Les 1 Segm Lumb","41870221","CDM","983","RC","22114","HCPCS","","","facility","both","","","","3181.8","3181.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Neop Id Em Thor","41870222","CDM","983","RC","63281","HCPCS","","","facility","both","","","","5802.09","5802.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Spine","41870223","CDM","983","RC","22899","HCPCS","","","facility","both","","","","1241.67","1241.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminotomy Single Lumbar","41870224","CDM","983","RC","63042","HCPCS","","","facility","both","","","","3711.14","3711.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted None Prsnt","41870225","CDM","983","RC","1126F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advnc Care Plan In Med Rec","41870226","CDM","983","RC","1157F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Med List Documented In Rcrd","41870227","CDM","983","RC","1159F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hg A1C Level < 7.0%","41870228","CDM","983","RC","3044F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C Level >9.0%","41870230","CDM","983","RC","3046F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Body Mass Index Docd","41870231","CDM","983","RC","3008F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","41870232","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","41870233","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","41870234","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","41870235","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","41870236","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","41870237","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smoking Status 2Nd Hand Smoke","41870238","CDM","983","RC","1031F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Smoker Or 2Nd Hand Smo","41870239","CDM","983","RC","1032F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Nonsmoker Nor 2Ndhnd","41870240","CDM","983","RC","1033F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Current Tobacco Smoker","41870241","CDM","983","RC","1034F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Smokeless Tobacco User","41870242","CDM","983","RC","1035F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tobacco Non-User","41870243","CDM","983","RC","1036F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amnt Pain Noted Pain Prsnt","41870244","CDM","983","RC","1125F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screening For Depression","41870245","CDM","983","RC","3725F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Replace Bone Flap/Prosth Plate","41870246","CDM","983","RC","62143","HCPCS","","","facility","both","","","","2920.38","2920.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Spine L S Ls","41870247","CDM","983","RC","22015","HCPCS","","","facility","both","","","","2752.26","2752.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Expl Supratentoria","41870248","CDM","983","RC","61304","HCPCS","","","facility","both","","","","4554.38","4554.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sp Bone Agrft Morsel Add-On","41870249","CDM","983","RC","20937","HCPCS","","","facility","both","","","","469.99","469.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Biomech Device Intrvert Ea","41870250","CDM","983","RC","22853","HCPCS","","","facility","both","","","","718.86","718.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Biomech Device Vert Ea Def","41870251","CDM","983","RC","22854","HCPCS","","","facility","both","","","","930.88","930.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Biomech Device Wo Intrbdy","41870252","CDM","983","RC","22859","HCPCS","","","facility","both","","","","930.88","930.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Stabli Dev W/Dcmprn Sngl","41870253","CDM","983","RC","22867","HCPCS","","","facility","both","","","","2811.95","2811.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Stabli Dev W/Dcmprn Lvl 2","41870254","CDM","983","RC","22868","HCPCS","","","facility","both","","","","675.92","675.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Stabli Dev W/O Dcmprn Sng","41870255","CDM","983","RC","22869","HCPCS","","","facility","both","","","","1331.17","1331.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Stabli Dev W/O Dcmprn 2Nd","41870256","CDM","983","RC","22870","HCPCS","","","facility","both","","","","360.57","360.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Crv/Thrc Wo I","41870257","CDM","983","RC","62320","HCPCS","","","facility","both","","","","507.12","507.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Crv/Thrc W Im","41870258","CDM","983","RC","62321","HCPCS","","","facility","both","","","","826.19","826.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Lmbr/Sac Wo I","41870259","CDM","983","RC","62322","HCPCS","","","facility","both","","","","466.72","466.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Interlaminar Lmbr/Sac W Im","41870260","CDM","983","RC","62323","HCPCS","","","facility","both","","","","819.73","819.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Intrlami Crv/Thrc Wo Imag/","41870261","CDM","983","RC","62324","HCPCS","","","facility","both","","","","434.71","434.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Intrlami Crv/Thrc W Imag/C","41870262","CDM","983","RC","62325","HCPCS","","","facility","both","","","","769.05","769.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Intrlami Lmbr/Sac Wo Imag/","41870263","CDM","983","RC","62326","HCPCS","","","facility","both","","","","451.27","451.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Intrlami Lmbr/Sac W Imag/C","41870264","CDM","983","RC","62327","HCPCS","","","facility","both","","","","791.43","791.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemoglobin A1C","41870265","CDM","300","RC","83037","HCPCS","","","facility","both","","","QW","22","22","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier QW: Clia waived test"
"Sp Bone Agrft Struct Add-On","41870266","CDM","983","RC","20938","HCPCS","","","facility","both","","","","510.47","510.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Spinal Lamina 2+ Segs","41870267","CDM","983","RC","63015","HCPCS","","","facility","both","","","","4156.67","4156.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore Spinal Fusion","41870268","CDM","983","RC","22830","HCPCS","","","facility","both","","","","2365.88","2365.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Harrington Rod","41870269","CDM","983","RC","22850","HCPCS","","","facility","both","","","","2114.9","2114.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Neurostim 2+ Arrays","41870270","CDM","983","RC","61886","HCPCS","","","facility","both","","","","2474.29","2474.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy W Exc Intradur Les","41870271","CDM","983","RC","63271","HCPCS","","","facility","both","","","","5734.22","5734.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dural Graft Spinal","41870272","CDM","983","RC","63710","HCPCS","","","facility","both","","","","3112.18","3112.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminotomy Addl Lumbar","41870273","CDM","983","RC","63044","HCPCS","","","facility","both","","","","1220.34","1220.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp 5/>Yrs","41870275","CDM","983","RC","99152","HCPCS","","","facility","both","","","","164.03","164.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp Ea","41870276","CDM","983","RC","99153","HCPCS","","","facility","both","","","","35.04","35.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp <5 Yrs","41870277","CDM","983","RC","99155","HCPCS","","","facility","both","","","","235.58","235.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Oth Phys/Qhp 5/>Yrs","41870278","CDM","983","RC","99156","HCPCS","","","facility","both","","","","220.09","220.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Other Phys/Qhp Ea","41870279","CDM","983","RC","99157","HCPCS","","","facility","both","","","","183.75","183.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remvl Of Spinal Lamina Lumbar","41870280","CDM","983","RC","63005","HCPCS","","","facility","both","","","","3381.52","3381.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","41870281","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Is Neopl Id Im","41870282","CDM","983","RC","63285","HCPCS","","","facility","both","","","","7202.02","7202.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spine Fusion Extra Segment","41870283","CDM","983","RC","22634","HCPCS","","","facility","both","","","","1379.12","1379.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rev/Rem Impl Spinal Ns Receivr","41870284","CDM","983","RC","63688","HCPCS","","","facility","both","","","","1085.67","1085.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue Add-On =<20 Sq","41870285","CDM","983","RC","11045","HCPCS","","","facility","both","","","","125.11","125.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Vertebral Art","41870286","CDM","983","RC","36226","HCPCS","","","facility","both","","","","6408.56","6408.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Xtrnl Carotid","41870287","CDM","983","RC","36227","HCPCS","","","facility","both","","","","767.97","767.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Carotid/Inom Art","41870288","CDM","983","RC","36223","HCPCS","","","facility","both","","","","5230.83","5230.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Carotd Art","41870289","CDM","983","RC","36224","HCPCS","","","facility","both","","","","6787.58","6787.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Spine Fx-1 Fx/Disl Vertebr","41870290","CDM","983","RC","22325","HCPCS","","","facility","both","","","","4167.74","4167.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Subclavian Art","41870291","CDM","983","RC","36225","HCPCS","","","facility","both","","","","5004.31","5004.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Halo Cranial","41870292","CDM","983","RC","20661","HCPCS","","","facility","both","","","","1492.44","1492.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Lesion Sgl Seg Intradur Th","41870293","CDM","983","RC","63305","HCPCS","","","facility","both","","","","6892.45","6892.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Thorax Spine Fusion","41870294","CDM","983","RC","22556","HCPCS","","","facility","both","","","","4739.68","4739.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole Trephine W Bx Brain","41870295","CDM","983","RC","61140","HCPCS","","","facility","both","","","","3540.47","3540.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Rem Abn Facet Lumb","41870296","CDM","983","RC","63012","HCPCS","","","facility","both","","","","3388.55","3388.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tot Disc Arthr 1 Intrspc Limbr","41870297","CDM","983","RC","22857","HCPCS","","","facility","both","","","","5168.52","5168.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem P Segment Instrument","41870298","CDM","983","RC","22852","HCPCS","","","facility","both","","","","2035.67","2035.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ionm In Operatng Room 15 Min","41870299","CDM","983","RC","95940","HCPCS","","","facility","both","","","","96.2","96.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy So W Lamin Decompr","41870300","CDM","983","RC","61343","HCPCS","","","facility","both","","","","6062.37","6062.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins/Repl Cranl Nstim-1 Elctr","41870301","CDM","983","RC","61885","HCPCS","","","facility","both","","","","1501.26","1501.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy - Exc Fenestr Cyst","41870303","CDM","983","RC","61516","HCPCS","","","facility","both","","","","5182.77","5182.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Decomp Sensry Root","41870304","CDM","983","RC","61450","HCPCS","","","facility","both","","","","5297.96","5297.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D P Spine C T Cert Thor","41870305","CDM","983","RC","22010","HCPCS","","","facility","both","","","","2782.6","2782.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incise Skull For Surgery 1+ Ne","41870306","CDM","983","RC","61460","HCPCS","","","facility","both","","","","5812.57","5812.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompressive Craniotomy","41870307","CDM","983","RC","61322","HCPCS","","","facility","both","","","","6567.02","6567.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Repl Csf Shunt Syst","41870308","CDM","983","RC","62258","HCPCS","","","facility","both","","","","3105.4","3105.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ventriculocisternostomy 3Rd Vt","41870309","CDM","983","RC","62200","HCPCS","","","facility","both","","","","3819.47","3819.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Colloid Cyst W Ic Scope","41870310","CDM","983","RC","62162","HCPCS","","","facility","both","","","","5227.9","5227.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brain Cavity Shunt Neuroendo","41870311","CDM","983","RC","62201","HCPCS","","","facility","both","","","","3391.12","3391.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminotomy Single Cervical","41870312","CDM","983","RC","63040","HCPCS","","","facility","both","","","","3951.49","3951.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spine Fusion Extra Segment","41870313","CDM","983","RC","22632","HCPCS","","","facility","both","","","","886.85","886.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Tongs/Halo","41870314","CDM","983","RC","20665","HCPCS","","","facility","both","","","","346.15","346.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Motor Evoked Uppr Limbs","41870316","CDM","983","RC","95928","HCPCS","","","facility","both","","","","725.4","725.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Procedure Nervous Sys","41870317","CDM","983","RC","64999","HCPCS","","","facility","both","","","","3029.18","3029.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spinal Puncture Lumbar Dx","41870318","CDM","983","RC","62270","HCPCS","","","facility","both","","","","436.93","436.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Csf Shunt Syst Wo Replace","41870319","CDM","983","RC","62256","HCPCS","","","facility","both","","","","1722.42","1722.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Brain Canal Inj W Meds","41870320","CDM","983","RC","61026","HCPCS","","","facility","both","","","","307.13","307.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ventric Punct Prev Hole Wo Inj","41870321","CDM","983","RC","61020","HCPCS","","","facility","both","","","","294.51","294.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Pituit Tumor W/Scope","41870322","CDM","983","RC","62165","HCPCS","","","facility","both","","","","4303.34","4303.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Cerebro Spinal Fluid","41870323","CDM","983","RC","62272","HCPCS","","","facility","both","","","","566.91","566.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy W Exc Fb Brain","41870325","CDM","983","RC","61570","HCPCS","","","facility","both","","","","5173.93","5173.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Elevate Skull Fx Smpl Extradur","41870326","CDM","983","RC","62000","HCPCS","","","facility","both","","","","2886.32","2886.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Cplx Postop Wnd Inf","41870327","CDM","983","RC","10180","HCPCS","","","facility","both","","","","787.83","787.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Csf Shnt Valve/Distl Cath","41870328","CDM","983","RC","62230","HCPCS","","","facility","both","","","","2366.97","2366.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Spinal Lamina 2+ Seg Thor","41870329","CDM","983","RC","63016","HCPCS","","","facility","both","","","","4275.32","4275.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluoroguide For Spine Inject","41870330","CDM","983","RC","77003","HCPCS","","","facility","both","","","26","324.84","324.84","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Inc For Vagus N Elect Impl","41870331","CDM","983","RC","64568","HCPCS","","","facility","both","","","","1798.93","1798.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Marrow Aspir Bone Grft","41870332","CDM","983","RC","20939","HCPCS","","","facility","both","","","","195.63","195.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Bone Marrow Bx Aspir","41870333","CDM","983","RC","38222","HCPCS","","","facility","both","","","","551.84","551.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrv Rpr W/Nrv Allograft 1St","41870334","CDM","983","RC","64912","HCPCS","","","facility","both","","","","2696.44","2696.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrv Rpr W/Nrv Algrft Ea Addl","41870335","CDM","983","RC","64913","HCPCS","","","facility","both","","","","518.91","518.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Unlisted Proc Nervous System","41870337","CDM","983","RC","64999","HCPCS","","","facility","both","","","","2753.01","2753.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompressive Lobectomy","41870338","CDM","983","RC","61323","HCPCS","","","facility","both","","","","6583.66","6583.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trt Thorax Spine Fx-1 Vertebra","41870339","CDM","983","RC","22327","HCPCS","","","facility","both","","","","4328.19","4328.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cath Intracranial Art","41870340","CDM","983","RC","36228","HCPCS","","","facility","both","","","","4328.73","4328.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Neuroma Cutaneous Nrv","41870341","CDM","983","RC","64774","HCPCS","","","facility","both","","","","1219.7","1219.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Exc Brain Tumor","41870342","CDM","983","RC","61518","HCPCS","","","facility","both","","","","7633.92","7633.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompress Spinal Cord Lumbar","41870343","CDM","983","RC","63056","HCPCS","","","facility","both","","","","4212.85","4212.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Bx Asp Exc Ic Lesion Ct Mri","41870344","CDM","983","RC","61751","HCPCS","","","facility","both","","","","3854.11","3854.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vagus N Eltrd","41870345","CDM","983","RC","64570","HCPCS","","","facility","both","","","","2081.2","2081.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy It Pf Exc Fenestr","41870346","CDM","983","RC","61524","HCPCS","","","facility","both","","","","5752.06","5752.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cerv Artific Diskectomy","41870347","CDM","983","RC","22856","HCPCS","","","facility","both","","","","4634.64","4634.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Second Level Cer Diskectomy","41870348","CDM","983","RC","22858","HCPCS","","","facility","both","","","","1422","1422","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Dural Csf Leak Laminectomy","41870349","CDM","983","RC","63709","HCPCS","","","facility","both","","","","3166.45","3166.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41870350","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cervical Laminoplasty 2+Segmen","41870351","CDM","983","RC","63050","HCPCS","","","facility","both","","","","4267.44","4267.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Function Cortical Map 1St Hr","41870352","CDM","983","RC","95961","HCPCS","","","facility","both","","","","968.12","968.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Is Neopl Thorac","41870353","CDM","983","RC","63276","HCPCS","","","facility","both","","","","4989.56","4989.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompress Spinal Cord Thoraci","41870354","CDM","983","RC","63055","HCPCS","","","facility","both","","","","4554.4","4554.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Exc Intradur Les L","41870355","CDM","983","RC","63272","HCPCS","","","facility","both","","","","5276.82","5276.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Orbitocranial Acf Wo Orbit Exe","41870356","CDM","983","RC","61584","HCPCS","","","facility","both","","","","8144.14","8144.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Or Exc Lesion Base Acf","41870357","CDM","983","RC","61601","HCPCS","","","facility","both","","","","6888.26","6888.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Brain Tum Sk Base","41870358","CDM","983","RC","61521","HCPCS","","","facility","both","","","","8738.7","8738.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Of Nerve","41870359","CDM","983","RC","64795","HCPCS","","","facility","both","","","","546.24","546.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Bx Deep","41870360","CDM","983","RC","20205","HCPCS","","","facility","both","","","","918.27","918.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Special Reports","41870362","CDM","983","RC","99080","HCPCS","","","facility","both","","","","257.5","257.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inc Rem Fb Sq Compl","41870363","CDM","983","RC","10121","HCPCS","","","facility","both","","","","839.6","839.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cut Spine 3 Col Lumb","41870364","CDM","983","RC","22207","HCPCS","","","facility","both","","","","6822.02","6822.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cut Spine 3 Col Addl Seg","41870365","CDM","983","RC","22208","HCPCS","","","facility","both","","","","1636.1","1636.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Elevate Depr Sk Fx W Dura Rep","41870366","CDM","983","RC","62010","HCPCS","","","facility","both","","","","4262.27","4262.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Att S A L D 10 Sq Cm","41870367","CDM","983","RC","14020","HCPCS","","","facility","both","","","","2119.48","2119.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vertebral Augmentation","41870368","CDM","983","RC","22513","HCPCS","","","facility","both","","","","22282.25","22282.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Exc Brain Absc","41870369","CDM","983","RC","61514","HCPCS","","","facility","both","","","","5287.45","5287.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep Bone Bx Trcr/Ndl","41870370","CDM","983","RC","20225","HCPCS","","","facility","both","","","","1355.17","1355.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Ea Add Spine Fx/Per Fx Seg","41870371","CDM","983","RC","22328","HCPCS","","","facility","both","","","","779.69","779.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Neopl Id Lumb","41870372","CDM","983","RC","63282","HCPCS","","","facility","both","","","","5484.63","5484.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Exc Is Les Thorac","41870373","CDM","983","RC","63266","HCPCS","","","facility","both","","","","4808.63","4808.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Electrocorticogram At Surgery","41870374","CDM","983","RC","95829","HCPCS","","","facility","both","","","","6146.03","6146.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vertebral Augmentation","41870375","CDM","983","RC","22514","HCPCS","","","facility","both","","","","22206.47","22206.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranioplasty Skull Deft To 5Cm","41870376","CDM","983","RC","62140","HCPCS","","","facility","both","","","","2890.25","2890.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Evac Hemat Infrat","41870377","CDM","983","RC","61315","HCPCS","","","facility","both","","","","5710.3","5710.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"C-Laminoplasty W/Graft/Plate","41870378","CDM","983","RC","63051","HCPCS","","","facility","both","","","","4842.24","4842.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sinusotomy Front Oblit Wo Inc","41870379","CDM","983","RC","31081","HCPCS","","","facility","both","","","","3428.97","3428.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intmd Wnd Repair S/A/T/Ext","41870380","CDM","983","RC","12031","HCPCS","","","facility","both","","","","795.42","795.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Obsv Hosp Same Date Iii 55 Min","41870381","CDM","983","RC","99236","HCPCS","","","facility","both","","","","624.59","624.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Fb Muscle Deep","41870382","CDM","983","RC","20525","HCPCS","","","facility","both","","","","1504.54","1504.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fna W/O Image","41870383","CDM","983","RC","10021","HCPCS","","","facility","both","","","","303.44","303.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Face 2.6-5Cm","41870384","CDM","983","RC","12013","HCPCS","","","facility","both","","","","349.89","349.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Neopl Ed Lumb","41870385","CDM","983","RC","63277","HCPCS","","","facility","both","","","","4390.19","4390.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vert Corpectomy Cerv Ea Add Se","41870386","CDM","983","RC","63082","HCPCS","","","facility","both","","","","737.53","737.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Smpl Cn Npgt Prgrmg","41870387","CDM","983","RC","95976","HCPCS","","","facility","both","","","","119.96","119.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Alys Cplx Cn Npgt Prgrmg","41870388","CDM","983","RC","95977","HCPCS","","","facility","both","","","","157.28","157.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mod Sed Same Phys/Qhp <5 Yrs","41870389","CDM","983","RC","99151","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Immunization Admin Single/Comb","41870390","CDM","983","RC","90471","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rep Dural Csf Leak Wo Laminect","41870391","CDM","983","RC","63707","HCPCS","","","facility","both","","","","2661.04","2661.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spine Eltrd Plate","41870392","CDM","983","RC","63662","HCPCS","","","facility","both","","","","2415.48","2415.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminect Imp Ns Electr Epidrl","41870393","CDM","983","RC","63655","HCPCS","","","facility","both","","","","2386.95","2386.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kroenlein W/Removal Of Lesion","41870394","CDM","983","RC","67420","HCPCS","","","facility","both","","","","5094.4","5094.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Icg Angiography Uni/Bilat","41870395","CDM","983","RC","92240","HCPCS","","","facility","both","","","","658.12","658.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"St Loc W/Ins Cath/Probe Rad Sr","41870396","CDM","983","RC","61770","HCPCS","","","facility","both","","","","4484.5","4484.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Spine Infusion Pump","41870397","CDM","983","RC","62361","HCPCS","","","facility","both","","","","1231.24","1231.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Complex S A L 1.1-2.5Cm","41870399","CDM","983","RC","13120","HCPCS","","","facility","both","","","","1115.78","1115.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Simple Wnd 2.6-7.5 Cm","41870400","CDM","983","RC","12002","HCPCS","","","facility","both","","","","337.51","337.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cl Tx Vertebrl Bdy Fx Wo/Manip","41870401","CDM","983","RC","22310","HCPCS","","","facility","both","","","","913.63","913.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminctmy W Exc Intrsp Les Cer","41870402","CDM","983","RC","63265","HCPCS","","","facility","both","","","","4668.53","4668.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Eeg 41-60 Minutes (Read Only)","41870403","CDM","983","RC","95812","HCPCS","","","facility","both","","","26","1080.44","1080.44","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Reinsert Spinal Fixation Devic","41870405","CDM","983","RC","22849","HCPCS","","","facility","both","","","","3724.87","3724.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lcl Surg Wnd/Deh Extens","41870406","CDM","983","RC","13160","HCPCS","","","facility","both","","","","2344.9","2344.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repr Encephalocele Skull Vault","41870407","CDM","983","RC","62120","HCPCS","","","facility","both","","","","6061.36","6061.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sinusotomy Oblit W Flp Coronal","41870408","CDM","983","RC","31085","HCPCS","","","facility","both","","","","3654.96","3654.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Infratemporal Pre-Auriculr Mcf","41870409","CDM","983","RC","61590","HCPCS","","","facility","both","","","","8856.43","8856.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Resect Exc Lesion Base Mcf Id","41870410","CDM","983","RC","61606","HCPCS","","","facility","both","","","","8288.72","8288.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fluorescein Icg Angiography","41870411","CDM","983","RC","92242","HCPCS","","","facility","both","","","","779.71","779.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis Pt Occiput-C2","41870412","CDM","983","RC","22590","HCPCS","","","facility","both","","","","4465.29","4465.29","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Abs Supratentorial","41870413","CDM","983","RC","61320","HCPCS","","","facility","both","","","","5246.03","5246.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Collect/Review Data From Pt","41870414","CDM","983","RC","99091","HCPCS","","","facility","both","","","","167.3","167.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Mntr Physiol Param Setup","41870415","CDM","983","RC","99453","HCPCS","","","facility","both","","","","61.31","61.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy W Exc Intradur Les","41870416","CDM","983","RC","63270","HCPCS","","","facility","both","","","","5649.43","5649.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","41870417","CDM","983","RC","10061","HCPCS","","","facility","both","","","","616.28","616.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","41870418","CDM","983","RC","99291","HCPCS","","","facility","both","","","","819.88","819.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","41870419","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Neopl Id E Cerv","41870420","CDM","983","RC","63280","HCPCS","","","facility","both","","","","5867.4","5867.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Spinal Lamina 2+ Seg Lumb","41870421","CDM","983","RC","63017","HCPCS","","","facility","both","","","","3556.66","3556.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Int Wnd Repr S/Tr/Ext 7.6-12.5","41870422","CDM","983","RC","12034","HCPCS","","","facility","both","","","","1011.48","1011.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burr Hole S Trephine W Drain","41870423","CDM","983","RC","61150","HCPCS","","","facility","both","","","","3753.8","3753.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroplasty Maj Periph Nrv","41870424","CDM","983","RC","64708","HCPCS","","","facility","both","","","","1513.43","1513.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ins Sq Rsvr Pump/Inf-Vent Cath","41870425","CDM","983","RC","61215","HCPCS","","","facility","both","","","","1462.86","1462.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Les Sc <2 Cm","41870426","CDM","983","RC","21011","HCPCS","","","facility","both","","","","1136.14","1136.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Prev Impl Epid Cath","41870427","CDM","983","RC","62355","HCPCS","","","facility","both","","","","799.33","799.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Decompress Spine Cord Add-On","41870428","CDM","983","RC","63057","HCPCS","","","facility","both","","","","887.76","887.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy W Exc Avm Thorac","41870429","CDM","983","RC","63251","HCPCS","","","facility","both","","","","8335.86","8335.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crep S A L 2.6 7.5Cm","41870430","CDM","983","RC","13121","HCPCS","","","facility","both","","","","1346.9","1346.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"C Rep S A L Ea Add 5 Cm","41870431","CDM","983","RC","13122","HCPCS","","","facility","both","","","","402.78","402.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Spine Eltrd Perq Aray","41870432","CDM","983","RC","63663","HCPCS","","","facility","both","","","","2673.69","2673.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Ben Sk Les Scalp <0.5Cm","41870433","CDM","983","RC","11420","HCPCS","","","facility","both","","","","400.36","400.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteotomy Spine/1 Vrt Sgm Thrc","41870434","CDM","983","RC","22212","HCPCS","","","facility","both","","","","4322.47","4322.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteotomy Spine/Ea Add Vrt Sgm","41870435","CDM","983","RC","22216","HCPCS","","","facility","both","","","","1017.9","1017.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis P Sp 7 12 Vert Seg","41870436","CDM","983","RC","22802","HCPCS","","","facility","both","","","","6037.45","6037.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Pelvic Fixation Device","41870437","CDM","983","RC","22848","HCPCS","","","facility","both","","","","1011.67","1011.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dx Lum Spnl Puncture Fluor/Ct","41870438","CDM","983","RC","62328","HCPCS","","","facility","both","","","","829.84","829.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tx Spnl Puncture Csf Fluor/Ct","41870439","CDM","983","RC","62329","HCPCS","","","facility","both","","","","1023.28","1023.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Nrvs Si Jnt W Img","41870440","CDM","983","RC","64451","HCPCS","","","facility","both","","","","672.54","672.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Aa Strd Genclar Nrv Brnch","41870441","CDM","983","RC","64454","HCPCS","","","facility","both","","","","679.7","679.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dstrc Nurlyt Agt Genicular Nrv","41870442","CDM","983","RC","64624","HCPCS","","","facility","both","","","","1311.65","1311.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rf Ablt Nrv Innervtng Si W/Img","41870443","CDM","983","RC","64625","HCPCS","","","facility","both","","","","1594.18","1594.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Face Tum Deep 2 Cm/>","41870444","CDM","983","RC","21014","HCPCS","","","facility","both","","","","1548.78","1548.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc B9 Les S N Ex G 1.1 2.0Cm","41870445","CDM","983","RC","11422","HCPCS","","","facility","both","","","","558.39","558.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Opn Odontoid Fx/Dis Ant Wo Grt","41870447","CDM","983","RC","22318","HCPCS","","","facility","both","","","","4590.56","4590.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Neck Spine Ant Appr","41870448","CDM","983","RC","22220","HCPCS","","","facility","both","","","","4570.91","4570.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shuntogram For Nv Shunt","41870449","CDM","983","RC","75809","HCPCS","","","facility","both","","","","284.67","284.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inf Pmp W Reprgm Fill","41870450","CDM","983","RC","62369","HCPCS","","","facility","both","","","","305.4","305.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","41870452","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","41870453","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","41870454","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","41870455","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","41870456","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Ii","41870457","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iii","41870458","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","41870459","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level V","41870460","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care I","41870462","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","41870463","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","41870464","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","41870466","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","41870467","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","41870468","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","41870469","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","41870470","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","41870471","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","41870472","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","41870473","CDM","983","RC","99497","HCPCS","","","facility","both","","","","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","41870474","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","41870475","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Annl Deprsn Scn,15","41870476","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","41870477","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","41870478","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","41870479","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","41870480","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","41870481","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"C Rep Trunk 1.1 2.5Cm","41870482","CDM","983","RC","13100","HCPCS","","","facility","both","","","","1072.59","1072.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","41870483","CDM","983","RC","97597","HCPCS","","","facility","both","","","","306.75","306.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41870484","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Analyze Neurostim Simple","41870485","CDM","983","RC","95971","HCPCS","","","facility","both","","","","149.97","149.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 5 10 Mins","41870486","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.7","43.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","41870487","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.71","86.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","41870488","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neuroplasty Sciatic Nerve","41870489","CDM","983","RC","64712","HCPCS","","","facility","both","","","","1699.38","1699.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","41870490","CDM","983","RC","11044","HCPCS","","","facility","both","","","","938.02","938.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Internal Neurolysis W/Microsc","41870491","CDM","983","RC","64727","HCPCS","","","facility","both","","","","519.66","519.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Vertebral Augmentation","41870492","CDM","983","RC","22515","HCPCS","","","facility","both","","","","12025.04","12025.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniotomy Ebf Lobectomy Only","41870493","CDM","983","RC","61539","HCPCS","","","facility","both","","","","6372.15","6372.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranioplasty W Autogrft To 5Cm","41870494","CDM","983","RC","62146","HCPCS","","","facility","both","","","","3153.55","3153.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Expl P Wnd Neck","41870495","CDM","983","RC","20100","HCPCS","","","facility","both","","","","1720.23","1720.23","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E M Service Ea 15Min","41870496","CDM","983","RC","G2212","HCPCS","","","facility","both","","","","86.81","86.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add  =<20Sq Cm","41870497","CDM","983","RC","11046","HCPCS","","","facility","both","","","","217.88","217.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrodesis P Sp To 6 Vertebr","41870498","CDM","983","RC","22800","HCPCS","","","facility","both","","","","3758.57","3758.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Neurolytic Epid Lumb Caudl","41870499","CDM","983","RC","62282","HCPCS","","","facility","both","","","","1030.46","1030.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx Is Neopl Thorac","41870500","CDM","983","RC","63286","HCPCS","","","facility","both","","","","6855.22","6855.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy Expl/Dec Cran Nrv","41870504","CDM","983","RC","61458","HCPCS","","","facility","both","","","","5368.93","5368.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranioplasty Rep Skull Brain","41870506","CDM","983","RC","62145","HCPCS","","","facility","both","","","","3778.3","3778.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Part Lumbar Vertebra","41870507","CDM","983","RC","22102","HCPCS","","","facility","both","","","","2332.62","2332.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remv Ex Spn Seg, 1 Vrt Segm Ea","41870508","CDM","983","RC","22103","HCPCS","","","facility","both","","","","377.83","377.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx/Exc Neo Cerv","41870509","CDM","983","RC","63275","HCPCS","","","facility","both","","","","4846.03","4846.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurp Maj Prph Nrv Arm/Leg Lum","41870510","CDM","983","RC","64714","HCPCS","","","facility","both","","","","2137.97","2137.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Transection/Avulsion Vagus Nrv","41870511","CDM","983","RC","64760","HCPCS","","","facility","both","","","","1445.76","1445.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vert Body Dcmprn Thrc","41870512","CDM","983","RC","63101","HCPCS","","","facility","both","","","","6260.7","6260.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Lumbar Artif Disc","41870513","CDM","983","RC","22862","HCPCS","","","facility","both","","","","6179.69","6179.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Insert Spine Fixation Device","41870514","CDM","983","RC","22844","HCPCS","","","facility","both","","","","2640.74","2640.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteotomy Spine Pst 3Clmn Thor","41870515","CDM","983","RC","22206","HCPCS","","","facility","both","","","","6633.69","6633.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthro Ant Fusion 2-3 Vert Seg","41870516","CDM","983","RC","22808","HCPCS","","","facility","both","","","","4987.24","4987.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Interm Scalp 2.6-7.5Cm","41870517","CDM","983","RC","12032","HCPCS","","","facility","both","","","","953.47","953.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Ea Add 30 Min","41870518","CDM","983","RC","99498","HCPCS","","","facility","both","","","","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spine Ant Fixation Dev","41870519","CDM","983","RC","22855","HCPCS","","","facility","both","","","","3031.11","3031.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prtl Rem Cervical Vert 1 Seg","41870520","CDM","983","RC","22110","HCPCS","","","facility","both","","","","2913.03","2913.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy W/Exc Tum/Les Skul","41870521","CDM","983","RC","61500","HCPCS","","","facility","both","","","","3556","3556","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Neuroelectrodes","41870522","CDM","983","RC","61860","HCPCS","","","facility","both","","","","4164.99","4164.99","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implt Cran Bone Flap To Abdo","41870523","CDM","983","RC","61316","HCPCS","","","facility","both","","","","226.39","226.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Ea Addl 30 Min","41870524","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Pelvic Fracture(S)","41870525","CDM","983","RC","G0412","HCPCS","","","facility","both","","","","2090.21","2090.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminectomy Bx/Exc Neo Thrlmb","41870526","CDM","983","RC","63287","HCPCS","","","facility","both","","","","7242.34","7242.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Spine Electrode Plate","41870527","CDM","983","RC","63664","HCPCS","","","facility","both","","","","2427.45","2427.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Osteotomy Spine 1 Vrt Sgm Lmbr","41870528","CDM","983","RC","22214","HCPCS","","","facility","both","","","","4166.14","4166.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prtl Exc Bony Les 1Vrt Sgm Crv","41870529","CDM","983","RC","22100","HCPCS","","","facility","both","","","","2425.14","2425.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniectomy/Otomy Exploratory","41870530","CDM","983","RC","61305","HCPCS","","","facility","both","","","","5332.31","5332.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Retr Bone Flap To Fix Skull","41870531","CDM","983","RC","62148","HCPCS","","","facility","both","","","","325.02","325.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Dura","41870532","CDM","983","RC","61618","HCPCS","","","facility","both","","","","3494.43","3494.43","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Spinal Shunt","41870533","CDM","983","RC","63746","HCPCS","","","facility","both","","","","1689.18","1689.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revision Of Spinal Shunt","41870534","CDM","983","RC","63744","HCPCS","","","facility","both","","","","1892.42","1892.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Spine Lamina 1/2 Scrl","41870535","CDM","983","RC","63011","HCPCS","","","facility","both","","","","3021.2","3021.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","41870536","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Release Spinal Cord Lumbar","41870537","CDM","983","RC","63200","HCPCS","","","facility","both","","","","4097.86","4097.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Interrogation Vad In Person","41870538","CDM","983","RC","93750","HCPCS","","","facility","both","","","","142.12","142.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incis 1 Vertebral Seg Cerv","41870539","CDM","983","RC","22210","HCPCS","","","facility","both","","","","4889.05","4889.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Catheter Fluid Drainage","41870540","CDM","983","RC","10030","HCPCS","","","facility","both","","","","2105.45","2105.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Brain Lesion","41870541","CDM","983","RC","61520","HCPCS","","","facility","both","","","","9903.27","9903.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cranioplasty W Autograft 5Cm","41870542","CDM","983","RC","62147","HCPCS","","","facility","both","","","","3829.16","3829.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lam Facetc/Frmt Arthrd Lum 1","41870543","CDM","983","RC","63052","HCPCS","","","facility","both","","","","679.44","679.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lam Factc/Frmt Arth Lum Ea Add","41870544","CDM","983","RC","63053","HCPCS","","","facility","both","","","","509.03","509.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inj Trigger Point 1-2 Muscles","41870545","CDM","983","RC","20552","HCPCS","","","facility","both","","","","169.57","169.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Laminotomy Addl Cervical","41870546","CDM","983","RC","63043","HCPCS","","","facility","both","","","","6060.91","6060.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bx/Exc Xdrl Spine Lesn Scrl","41870547","CDM","983","RC","63278","HCPCS","","","facility","both","","","","4275.38","4275.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Srgry Cmptr Ct/Mri Imag","41870548","CDM","983","RC","0055T","HCPCS","","","facility","both","","","","5703.37","5703.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Craniofacial Approach Skull","41870549","CDM","983","RC","61583","HCPCS","","","facility","both","","","","8004.37","8004.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Skull Fracture","41870550","CDM","983","RC","62005","HCPCS","","","facility","both","","","","3413.61","3413.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kyphectomy 3 Or More","41870551","CDM","983","RC","22819","HCPCS","","","facility","both","","","","6825.53","6825.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Brain Lining Lesion","41870552","CDM","983","RC","61519","HCPCS","","","facility","both","","","","7750.24","7750.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Appl Crnl Tng/Strt W/Rmvl Spx","41870553","CDM","983","RC","20660","HCPCS","","","facility","both","","","","633.48","633.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excsn Bn Mandbl","41870554","CDM","983","RC","21025","HCPCS","","","facility","both","","","","2316.94","2316.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Vertebroplasty Addl Inject","41870555","CDM","983","RC","22512","HCPCS","","","facility","both","","","","2346.89","2346.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Vrtbrplst Injx Crvcthrcc","41870556","CDM","983","RC","22510","HCPCS","","","facility","both","","","","5915.58","5915.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prq Vrtbrplsty Uni/Bi Inj Lmbs","41870557","CDM","983","RC","22511","HCPCS","","","facility","both","","","","2366.91","2366.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Superficial Implant","41870558","CDM","983","RC","20670","HCPCS","","","facility","both","","","","451.96","451.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dissect Brain W Scope","41870559","CDM","983","RC","62161","HCPCS","","","facility","both","","","","4102.8","4102.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Needle Localization By Xray","41870560","CDM","983","RC","77002","HCPCS","","","facility","both","","","","75.5","75.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ntrprf Phn/Ntrnt Asmt 31/>Min","41870561","CDM","983","RC","99449","HCPCS","","","facility","both","","","","200.42","200.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mri Brain Stem W/O Dye","41870562","CDM","983","RC","70551","HCPCS","","","facility","both","","","","198.74","198.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise/Repl Vagus N Eltrd","41870563","CDM","983","RC","64569","HCPCS","","","facility","both","","","","2115.24","2115.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Drain Neck/Chest Lesion","41870564","CDM","983","RC","21501","HCPCS","","","facility","both","","","","1495.8","1495.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Vrtbl Body Lmbr/Crvcl","41870565","CDM","983","RC","20251","HCPCS","","","facility","both","","","","1185.41","1185.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Open Vrtbl Body Thrcc","41870566","CDM","983","RC","20250","HCPCS","","","facility","both","","","","1099.2","1099.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr S/N/Ax/Gen/Trnk 2.5 Cm/<","41870567","CDM","983","RC","12001","HCPCS","","","facility","both","","","","285.16","285.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","41870568","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Spin/Brain Pump Refil & Main","41870570","CDM","983","RC","95991","HCPCS","","","facility","both","","","","343.09","343.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Test 2 Limbs","41870571","CDM","983","RC","95861","HCPCS","","","facility","both","","","","228.09","228.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ntrprof Ph1/Ntrnet/Her/ 5/>","41870572","CDM","983","RC","99451","HCPCS","","","facility","both","","","","87.24","87.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthr Si Jt Opn B1Grf Instrm","41870573","CDM","983","RC","27280","HCPCS","","","facility","both","","","","3743.82","3743.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Vert Body Cdmprn Lmbr","41870574","CDM","983","RC","63090","HCPCS","","","facility","both","","","","5290.65","5290.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rpr Bld Vssl Lsn","41870575","CDM","983","RC","35201","HCPCS","","","facility","both","","","","2442.59","2442.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nerve Repair W/Allograft","41870576","CDM","983","RC","64910","HCPCS","","","facility","both","","","","2198.62","2198.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Of Low Back Nerves","41870577","CDM","983","RC","64862","HCPCS","","","facility","both","","","","3842.52","3842.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Explore Wound Abdomen","41870578","CDM","983","RC","20102","HCPCS","","","facility","both","","","","1886.81","1886.81","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Dura","41870579","CDM","983","RC","61619","HCPCS","","","facility","both","","","","3930.3","3930.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Injection Into Brain Canal","41870580","CDM","983","RC","61055","HCPCS","","","facility","both","","","","324.48","324.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Revise Ulnar Nerve At Elbow","41870581","CDM","983","RC","64718","HCPCS","","","facility","both","","","","1774.98","1774.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrd Pre-Sac Ntrbdy L5-S1","41870582","CDM","983","RC","22586","HCPCS","","","facility","both","","","","5475.05","5475.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Lamot/Lam Lumbar","41870583","CDM","983","RC","0275T","HCPCS","","","facility","both","","","","3708","3708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Brain Canal Fluid","41870584","CDM","983","RC","61050","HCPCS","","","facility","both","","","","225.26","225.26","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ther/Proph/Diag Inj Sc/Im","41870585","CDM","983","RC","96372","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Perq Lamot Lam Crv Thrc","41870586","CDM","983","RC","0274T","HCPCS","","","facility","both","","","","3708","3708","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treat Tail Bone Fracture","41870587","CDM","983","RC","27202","HCPCS","","","facility","both","","","","1520.33","1520.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Tail Bone","41870588","CDM","983","RC","27080","HCPCS","","","facility","both","","","","1463.89","1463.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Brain Lesion","41870590","CDM","983","RC","61526","HCPCS","","","facility","both","","","","9045.56","9045.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrd Ant Dfrm 8+ Vrt Sgm","41870591","CDM","983","RC","22812","HCPCS","","","facility","both","","","","6061.91","6061.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Twist Drill Hole","41870592","CDM","983","RC","61105","HCPCS","","","facility","both","","","","1305.45","1305.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrd Ant Dfrm 4-7 Vrt Sgm","41870593","CDM","983","RC","22810","HCPCS","","","facility","both","","","","5592.9","5592.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Complex E/M Visit Add On","41870594","CDM","983","RC","G2211","HCPCS","","","facility","both","","","","78.9","78.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Rpr Trunk Addl 5Cm/<","41870595","CDM","983","RC","13102","HCPCS","","","facility","both","","","","370.61","370.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Rpr Trunk 2.6-7.5 Cm","41870596","CDM","983","RC","13101","HCPCS","","","facility","both","","","","1261.06","1261.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incise Skull For Brain Wound","41870597","CDM","983","RC","61571","HCPCS","","","facility","both","","","","5348.33","5348.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Intracranial Vessel Surgery","41870598","CDM","983","RC","61684","HCPCS","","","facility","both","","","","7543.57","7543.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Repair Brain Fluid Leakage","41870599","CDM","983","RC","62100","HCPCS","","","facility","both","","","","4288.51","4288.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrd Pst Dfrm 13+ Vrt Sgm","41870600","CDM","983","RC","22804","HCPCS","","","facility","both","","","","6473","6473","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incision Of Spinal Nerve","41870601","CDM","983","RC","64772","HCPCS","","","facility","both","","","","1670.3","1670.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Arthrd Ant Toral/Xoral C1C2","41870602","CDM","983","RC","22548","HCPCS","","","facility","both","","","","5177.38","5177.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Removal Of Brain Tissue","41870603","CDM","983","RC","61537","HCPCS","","","facility","both","","","","6307.1","6307.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Level Ii","43101003","CDM","510","RC","99202","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","43101004","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Level Iii","43101005","CDM","510","RC","99203","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","43101006","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Level Iv","43101007","CDM","510","RC","99204","HCPCS","","","facility","both","","","","288","288","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","43101008","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit New Level V","43101009","CDM","510","RC","99205","HCPCS","","","facility","both","","","","378","378","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","43101010","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Ext Level I","43101011","CDM","510","RC","99211","HCPCS","","","facility","both","","","","117","117","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","43101012","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Est Level Ii","43101013","CDM","510","RC","99212","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","43101014","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Est Lev Iii","43101015","CDM","510","RC","99213","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","43101016","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Est Lev Iv","43101017","CDM","510","RC","99214","HCPCS","","","facility","both","","","","223","223","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","43101018","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Off Visit Est Level V","43101019","CDM","510","RC","99215","HCPCS","","","facility","both","","","","288","288","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","43101020","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Init 30 Min","43101021","CDM","983","RC","99497","HCPCS","","","facility","both","","","","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Advncd Care Plan Ea Add 30 Min","43101022","CDM","983","RC","99498","HCPCS","","","facility","both","","","","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","43101023","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","43101024","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","43101025","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","43101026","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","43101027","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","43101028","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","43101029","CDM","983","RC","99238","HCPCS","","","facility","both","","","","212.98","212.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hosp Dc Manage 30 Min Md","43101030","CDM","983","RC","99239","HCPCS","","","facility","both","","","","312.63","312.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","43101031","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Facility Care Lvl I","43101032","CDM","983","RC","99304","HCPCS","","","facility","both","","","","262.6","262.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Lvl Ii","43101033","CDM","983","RC","99305","HCPCS","","","facility","both","","","","377.86","377.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Facility Care Lvl Iii","43101034","CDM","983","RC","99306","HCPCS","","","facility","both","","","","485.39","485.39","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl I","43101035","CDM","983","RC","99307","HCPCS","","","facility","both","","","","128.72","128.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl Ii","43101036","CDM","983","RC","99308","HCPCS","","","facility","both","","","","203.04","203.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subs Lvl Iii","43101037","CDM","983","RC","99309","HCPCS","","","facility","both","","","","268.32","268.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nursing Fac Care Subseq Lvl Iv","43101038","CDM","983","RC","99310","HCPCS","","","facility","both","","","","394.56","394.56","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snf D C Day 30 Min","43101039","CDM","983","RC","99315","HCPCS","","","facility","both","","","","214.17","214.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Snf D C Day 30 Min","43101040","CDM","983","RC","99316","HCPCS","","","facility","both","","","","307.4","307.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cmplx Chron Care W/O Pt Visit","43101042","CDM","983","RC","99487","HCPCS","","","facility","both","","","","280.57","280.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Visit Est Pt Lvl I","43101044","CDM","983","RC","99347","HCPCS","","","facility","both","","","","159.62","159.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Visit Est Patient Lvl Ii","43101045","CDM","983","RC","99348","HCPCS","","","facility","both","","","","244.24","244.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","43101046","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","43101047","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","43101048","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","43101049","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Visit Est Patient Lvl Iii","43101054","CDM","983","RC","99349","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Assmt/Care Pln Pt Cog Imp","43101055","CDM","983","RC","99483","HCPCS","","","facility","both","","","","788.93","788.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Visit New Patient Lvl Iv","43101057","CDM","983","RC","99344","HCPCS","","","facility","both","","","","529.19","529.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Init Hosp Care I","43101058","CDM","983","RC","99221","HCPCS","","","facility","both","","","95","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Ii","43101059","CDM","983","RC","99222","HCPCS","","","facility","both","","","95","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Init Hosp Care Iii","43101060","CDM","983","RC","99223","HCPCS","","","facility","both","","","95","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Ii","43101062","CDM","983","RC","99242","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iii","43101063","CDM","983","RC","99243","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level Iv","43101064","CDM","983","RC","99244","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Consult Level V","43101065","CDM","983","RC","99245","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care 30 Min","43101066","CDM","983","RC","99497","HCPCS","","","facility","both","","","95","250.24","250.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Adv Care Plan 30M","43101067","CDM","983","RC","99498","HCPCS","","","facility","both","","","95","216.49","216.49","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Home Visit New Patient Lvl Ii","43101068","CDM","983","RC","99342","HCPCS","","","facility","both","","","","222.05","222.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Home Visit Est Patient Lvl Iii","43101072","CDM","983","RC","99349","HCPCS","","","facility","both","","","","498.14","498.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shave Lesion Trunk/Ext 1.1-2Cm","43101073","CDM","983","RC","11302","HCPCS","","","facility","both","","","","446.48","446.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolonged E/M Service; Ea 15Mi","43101078","CDM","983","RC","99417","HCPCS","","","facility","both","","","","91.62","91.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care 1St 30 -74 Mins","43101079","CDM","983","RC","99291","HCPCS","","","facility","both","","","","790.37","790.37","","","","","","","","","","","","","Gross Charge Type: Standard"
"Critical Care Addl 30 Min","43101080","CDM","983","RC","99292","HCPCS","","","facility","both","","","","354.91","354.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Service W/O Contact","43101081","CDM","983","RC","99358","HCPCS","","","facility","both","","","","323.32","323.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolng Ip/Obs E/M Ea 15 Min","43101082","CDM","983","RC","99418","HCPCS","","","facility","both","","","","89.66","89.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prolong Inpt Eval Add 15 M","43101083","CDM","983","RC","G0316","HCPCS","","","facility","both","","","","90.62","90.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg; Adaptic Touch Silicone 3","44881230","CDM","623","RC","A6206","HCPCS","","","facility","both","","","","6.17","6.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg; Adaptic Touch Silicone 3","44881231","CDM","623","RC","A6206","HCPCS","","","facility","both","","","","17.27","17.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg; Adaptic Touch Silicone 5","44881232","CDM","272","RC","A6207","HCPCS","","","facility","both","","","","23.74","23.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg; Adaptic Touch Silicone 8","44881233","CDM","272","RC","A6208","HCPCS","","","facility","both","","","","31.8","31.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Contact Layer >16<= 48 Sq In","44881234","CDM","623","RC","A6207","HCPCS","","","facility","both","","","","15","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Pad Band W>=3"""" <5""""/Yd""","44881235","CDM","270","RC","A6441","HCPCS","","","facility","both","","","","15","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Conform Band N/S W>=3""""<5""""/Yd""","44881236","CDM","270","RC","A6443","HCPCS","","","facility","both","","","","15","15","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Lt Compres Band >=3"""" <5""""/Yd""","44881237","CDM","270","RC","A6449","HCPCS","","","facility","both","","","","16.65","16.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Albuterol 90 Mcg 8 Gm","44881238","CDM","637","RC","","","","","facility","both","","","","9","9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Bil-Unna Boot Applicat","44881239","CDM","510","RC","29580","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Profore Foot","44884005","CDM","272","RC","","","","","facility","both","","","","61.3","61.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Medic Unna Boot 3In X 10Yd W/C","44884006","CDM","623","RC","A6456","HCPCS","","","facility","both","","","","41.6","41.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Gft Skn Sub F/S/E >/=100Cm","44884007","CDM","983","RC","15277","HCPCS","","","facility","both","","","","1034.66","1034.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Gft Skn Sub F/S/E >/=1","44884008","CDM","510","RC","15277","HCPCS","","","facility","both","","","","2514","2514","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Grft T/Arm/Lg Child","44884010","CDM","983","RC","15273","HCPCS","","","facility","both","","","","947.45","947.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Sub Grft T/A/L Child Add","44884012","CDM","983","RC","15274","HCPCS","","","facility","both","","","","241.48","241.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Exc Bc/Bt Foot Phalange","44884017","CDM","983","RC","28108","HCPCS","","","facility","both","","","","1393.11","1393.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Short Arm Cast","44884019","CDM","983","RC","29075","HCPCS","","","facility","both","","","","264.61","264.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apligraf","44884021","CDM","278","RC","Q4101","HCPCS","","","facility","both","","","JC","2676.77","2676.77","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier JC: Skin substitute used as a graft"
"Matristem Wound Mtrx 12.5 Sq C","44884022","CDM","636","RC","Q4166","HCPCS","","","facility","both","","","","129.02","129.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care I 30 Min","44884023","CDM","983","RC","99221","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Ii 50 Mi","44884025","CDM","983","RC","99222","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Glucose 15, Oral Glucose Gel","44884026","CDM","250","RC","","","","","facility","both","","","","9.48","9.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"*Afrin (Oxymetazoline) 0.05% N","44884028","CDM","250","RC","","","","","facility","both","","","","4.92","4.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Initial Hospital Care Iii 70 M","44884029","CDM","983","RC","99223","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mcr/Comm Hbot 30 Min Intervals","44884039","CDM","413","RC","G0277","HCPCS","","","facility","both","","","","403","403","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Ii","44884040","CDM","983","RC","99252","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iii","44884042","CDM","983","RC","99253","HCPCS","","","facility","both","","","","290.36","290.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl Iv","44884043","CDM","983","RC","99254","HCPCS","","","facility","both","","","","394.54","394.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Inpatient Consult Lvl V","44884044","CDM","983","RC","99255","HCPCS","","","facility","both","","","","581.71","581.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care I","44884045","CDM","983","RC","99231","HCPCS","","","facility","both","","","","112.48","112.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Ii","44884046","CDM","983","RC","99232","HCPCS","","","facility","both","","","","208.35","208.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mcal Hbot Initial 15 Min","44884047","CDM","413","RC","Z7606","HCPCS","","","facility","both","","","","58","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Subsequent Hosp Care Iii","44884048","CDM","983","RC","99233","HCPCS","","","facility","both","","","","300.3","300.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit I","44884049","CDM","983","RC","99281","HCPCS","","","facility","both","","","","62.85","62.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Ii","44884050","CDM","983","RC","99282","HCPCS","","","facility","both","","","","121.11","121.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iii","44884051","CDM","983","RC","99283","HCPCS","","","facility","both","","","","180.92","180.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit Iv","44884052","CDM","983","RC","99284","HCPCS","","","facility","both","","","","330.22","330.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Emergency Dept Visit V","44884053","CDM","983","RC","99285","HCPCS","","","facility","both","","","","478.64","478.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mcal Hbot Subseq 15 Mins","44884054","CDM","413","RC","Z7608","HCPCS","","","facility","both","","","","58","58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deep Dissect Foot Inf Sgl Burs","44884055","CDM","983","RC","28002","HCPCS","","","facility","both","","","","1371.96","1371.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Single Les","44884057","CDM","983","RC","11102","HCPCS","","","facility","both","","","","319.59","319.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tangential Bx Skin Ea Add Les","44884058","CDM","983","RC","11103","HCPCS","","","facility","both","","","","168.71","168.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","44884059","CDM","983","RC","11104","HCPCS","","","facility","both","","","","402.35","402.35","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Add Les","44884060","CDM","983","RC","11105","HCPCS","","","facility","both","","","","192.32","192.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incisional Bx Skin Single Les","44884061","CDM","983","RC","11106","HCPCS","","","facility","both","","","","488.15","488.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Incal Bx Skn Ea Add Les","44884063","CDM","983","RC","11107","HCPCS","","","facility","both","","","","228.66","228.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit New Pt Level Ii","44884065","CDM","983","RC","99202","HCPCS","","","facility","both","","","95","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iii","44884066","CDM","983","RC","99203","HCPCS","","","facility","both","","","95","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level Iv","44884067","CDM","983","RC","99204","HCPCS","","","facility","both","","","95","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit New Pt Level V","44884068","CDM","983","RC","99205","HCPCS","","","facility","both","","","95","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level I","44884069","CDM","983","RC","99211","HCPCS","","","facility","both","","","95","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Visit New Level Ii","44884070","CDM","510","RC","99202","HCPCS","","","facility","both","","","","274","274","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Est Pt Level Iii","44884071","CDM","983","RC","99213","HCPCS","","","facility","both","","","95","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Dispos Neg Prss Wnd Tx  50Sqcm","44884073","CDM","510","RC","97607","HCPCS","","","facility","both","","","","515","515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Disposable-Neg Press Wound Tx","44884074","CDM","510","RC","97608","HCPCS","","","facility","both","","","","515","515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Est Pt Level Ii","44884076","CDM","983","RC","99212","HCPCS","","","facility","both","","","95","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Est Pt Level Iv","44884077","CDM","983","RC","99214","HCPCS","","","facility","both","","","95","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Dressing Extrasorb 4 X 5","44884078","CDM","623","RC","A6252","HCPCS","","","facility","both","","","","23.41","23.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Foam Alevyn 4 X 4","44884079","CDM","272","RC","A6212","HCPCS","","","facility","both","","","","11.13","11.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Crtdg Wnd 5.2X2.3In Snp Thk1In","44884080","CDM","279","RC","","","","","facility","both","","","","285.24","285.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Drsg 15X15Cm Snp Fm Adv","44884081","CDM","272","RC","A6550","HCPCS","","","facility","both","","","","92.5","92.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Drsg Snap Foam L14 Cm","44884082","CDM","272","RC","A6550","HCPCS","","","facility","both","","","","144.55","144.55","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Drsg Securring Snap Hy","44884083","CDM","272","RC","A6550","HCPCS","","","facility","both","","","","20.17","20.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Strap Neg Prss 53Cm Snp + Med","44884084","CDM","272","RC","A6550","HCPCS","","","facility","both","","","","60.02","60.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rem Adh Clrls Aers","44884085","CDM","279","RC","A4455","HCPCS","","","facility","both","","","","13.6","13.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ring Ost Bg 13/16In Adapt","44884086","CDM","279","RC","A4404","HCPCS","","","facility","both","","","","8.82","8.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dev Drn 5-40Fr Flxwr Hrzn Tube","44884087","CDM","279","RC","A5200","HCPCS","","","facility","both","","","","17.96","17.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Level Iii","44884088","CDM","510","RC","99203","HCPCS","","","facility","both","","","","308","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Est Pt Level V","44884090","CDM","983","RC","99215","HCPCS","","","facility","both","","","95","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Phone Visit E/M By Phys 5-10M","44884091","CDM","983","RC","99441","HCPCS","","","facility","both","","","","41.41","41.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 11-20M","44884092","CDM","983","RC","99442","HCPCS","","","facility","both","","","","80.75","80.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Phone Visit E/M Phy/Qhp 21-30M","44884093","CDM","983","RC","99443","HCPCS","","","facility","both","","","","118.02","118.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Alcohol Misuse 15M","44884094","CDM","983","RC","G0442","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Ftf Couns-Alcoh 15","44884095","CDM","983","RC","G0443","HCPCS","","","facility","both","","","95","75.17","75.17","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Visit New Level Iv","44884096","CDM","510","RC","99204","HCPCS","","","facility","both","","","","323","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Video Visit Annl Deprsn Scn,15","44884097","CDM","983","RC","G0444","HCPCS","","","facility","both","","","95","54.83","54.83","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking 3-10","44884098","CDM","983","RC","99406","HCPCS","","","facility","both","","","95","44.94","44.94","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behav Smoking>10","44884099","CDM","983","RC","99407","HCPCS","","","facility","both","","","95","83.91","83.91","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv15-30","44884100","CDM","983","RC","G0396","HCPCS","","","facility","both","","","95","104.72","104.72","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Alc/Sub Intrv >30","44884101","CDM","983","RC","G0397","HCPCS","","","facility","both","","","95","189.31","189.31","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Video Visit Behv Coun Obsty 15","44884102","CDM","983","RC","G0447","HCPCS","","","facility","both","","","95","76.89","76.89","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System"
"Online Digital E M 5 10 Mins","44884103","CDM","983","RC","99421","HCPCS","","","facility","both","","","","43.69","43.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit New Level V","44884104","CDM","510","RC","99205","HCPCS","","","facility","both","","","","331","331","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 11 20 Mins","44884105","CDM","983","RC","99422","HCPCS","","","facility","both","","","","86.7","86.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Online Digital E M 21 Mins","44884106","CDM","983","RC","99423","HCPCS","","","facility","both","","","","140.34","140.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp >= 140 Mm Hg","44884107","CDM","983","RC","3077F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp < 80 Mm Hg","44884108","CDM","983","RC","3078F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp 80-89 Mm Hg","44884109","CDM","983","RC","3079F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Diast Bp >= 90 Mm Hg","44884110","CDM","983","RC","3080F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Ge 130 - 139Mm Hg","44884111","CDM","983","RC","3075F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level I","44884112","CDM","510","RC","99211","HCPCS","","","facility","both","","","","202","202","","","","","","","","","","","","","Gross Charge Type: Standard"
"Syst Bp Lt 130 Mm Hg","44884113","CDM","983","RC","3074F","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Ii","44884120","CDM","510","RC","99212","HCPCS","","","facility","both","","","","301","301","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Iii","44884138","CDM","510","RC","99213","HCPCS","","","facility","both","","","","308","308","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level Iv","44884146","CDM","510","RC","99214","HCPCS","","","facility","both","","","","323","323","","","","","","","","","","","","","Gross Charge Type: Standard"
"Visit Estab Level V","44884153","CDM","510","RC","99215","HCPCS","","","facility","both","","","","364","364","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Level Ii","44884179","CDM","510","RC","99242","HCPCS","","","facility","both","","","","128","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grafixpl Prime 3 X 4 Cm (12 Sq","44884220","CDM","636","RC","Q4133","HCPCS","","","facility","both","","","","1923.75","1923.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee I And D Abscess Simple","44884229","CDM","510","RC","10060","HCPCS","","","facility","both","","","","442","442","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Apply Bil  Multlay Com","44884230","CDM","510","RC","29581","HCPCS","","","facility","both","","","","441","441","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee I And D Abscess Compli","44884237","CDM","510","RC","10061","HCPCS","","","facility","both","","","","515","515","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Devital Tis 20 Cm/<","44884294","CDM","510","RC","97597","HCPCS","","","facility","both","","","","427","427","","","","","","","","","","","","","Gross Charge Type: Standard"
"Rmvl Devital Tis Addl 20 Cm<","44884302","CDM","510","RC","97598","HCPCS","","","facility","both","","","","427","427","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","44884310","CDM","510","RC","11042","HCPCS","","","facility","both","","","","592","592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia 20 Sq Cm/<","44884328","CDM","510","RC","11043","HCPCS","","","facility","both","","","","917","917","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","44884336","CDM","510","RC","11044","HCPCS","","","facility","both","","","","2504","2504","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Benign Lesion Paring (1)","44884344","CDM","510","RC","11055","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Benign Lesion Paring (2-4)","44884351","CDM","510","RC","11056","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Benign Lesion Paring (4+)","44884369","CDM","510","RC","11057","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Cautery Wound-Chemical","44884476","CDM","510","RC","17250","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Unna Boot Application","44884575","CDM","510","RC","29580","HCPCS","","","facility","both","","","","254","254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Debride Nails 1-5","44884583","CDM","510","RC","11720","HCPCS","","","facility","both","","","","146","146","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Debride Nails >6","44884591","CDM","510","RC","11721","HCPCS","","","facility","both","","","","165","165","","","","","","","","","","","","","Gross Charge Type: Standard"
"Upr/L Xtremity Art 2 Levels","44884682","CDM","921","RC","93922","HCPCS","","","facility","both","","","TC","100","100","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
"I D Absc Smpl Or Sgl","44884708","CDM","983","RC","10060","HCPCS","","","facility","both","","","","375.9","375.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Abscess Complicated Mult","44884716","CDM","983","RC","10061","HCPCS","","","facility","both","","","","638.6","638.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Simple","44884724","CDM","983","RC","10120","HCPCS","","","facility","both","","","","479.72","479.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Hematoma Fluid","44884732","CDM","983","RC","10140","HCPCS","","","facility","both","","","","530.14","530.14","","","","","","","","","","","","","Gross Charge Type: Standard"
"Puncture Drainage Of Lesion","44884740","CDM","983","RC","10160","HCPCS","","","facility","both","","","","406.03","406.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"I D Cplx Postop Wnd Inf","44884757","CDM","983","RC","10180","HCPCS","","","facility","both","","","","787.83","787.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Ext Ecz/Inf Skin","44884765","CDM","983","RC","11000","HCPCS","","","facility","both","","","","175.41","175.41","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem 20 Cm/<","44884773","CDM","983","RC","97597","HCPCS","","","facility","both","","","","306.75","306.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Slctv Wnd Debridem Add 20 Cm/<","44884781","CDM","983","RC","97598","HCPCS","","","facility","both","","","","141.66","141.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue 20 Sq Cm/<","44884799","CDM","983","RC","11042","HCPCS","","","facility","both","","","","396.45","396.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Deb Musc/Fascia 20 Sq Cm/<","44884807","CDM","983","RC","11043","HCPCS","","","facility","both","","","","706.07","706.07","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone 20 Sq Cm/<","44884815","CDM","983","RC","11044","HCPCS","","","facility","both","","","","938.02","938.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion Single","44884823","CDM","983","RC","11055","HCPCS","","","facility","both","","","","203.01","203.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion 2-4","44884831","CDM","983","RC","11056","HCPCS","","","facility","both","","","","236.64","236.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Paring Benign Lesion >4","44884849","CDM","983","RC","11057","HCPCS","","","facility","both","","","","258.63","258.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Nondystrophic Nails Any#","44884872","CDM","983","RC","11719","HCPCS","","","facility","both","","","","43.52","43.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails 1-5","44884880","CDM","983","RC","11720","HCPCS","","","facility","both","","","","102.2","102.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debridement Nails >6","44884898","CDM","983","RC","11721","HCPCS","","","facility","both","","","","139.18","139.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Simpl Avulsion Nail Plt Single","44884906","CDM","983","RC","11730","HCPCS","","","facility","both","","","","346.54","346.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Avulsion Nail Ea 2+","44884914","CDM","983","RC","11732","HCPCS","","","facility","both","","","","103.36","103.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Excise Nail/Matrix Perm Remove","44884922","CDM","983","RC","11750","HCPCS","","","facility","both","","","","489.79","489.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abrasion Single Lesion","44884971","CDM","983","RC","15786","HCPCS","","","facility","both","","","","761.66","761.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"Abrasion Lesion Ea Add'l 4/<","44884989","CDM","983","RC","15787","HCPCS","","","facility","both","","","","128.98","128.98","","","","","","","","","","","","","Gross Charge Type: Standard"
"Destruction Skin Lesion 1St","44884997","CDM","983","RC","17000","HCPCS","","","facility","both","","","","203.84","203.84","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cauterize Granulation Tissue","44885002","CDM","983","RC","17250","HCPCS","","","facility","both","","","","271.87","271.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Muscle Superficial","44885028","CDM","983","RC","20200","HCPCS","","","facility","both","","","","668.57","668.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Muscle Bx Deep","44885036","CDM","983","RC","20205","HCPCS","","","facility","both","","","","918.27","918.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Muscle Perc Needle","44885044","CDM","983","RC","20206","HCPCS","","","facility","both","","","","779.69","779.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Bone Superficial","44885051","CDM","983","RC","20220","HCPCS","","","facility","both","","","","796.65","796.65","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Mepilex 6 X 8","44885063","CDM","623","RC","A6210","HCPCS","","","facility","both","","","","17.67","17.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Maxorb Ca Ag With Silver","44885064","CDM","272","RC","A6197","HCPCS","","","facility","both","","","","15.4","15.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Optifoam 6 X 6","44885065","CDM","623","RC","A6213","HCPCS","","","facility","both","","","","13.64","13.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Optifoam 4 X 4","44885066","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","9.06","9.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Duoderm 4 X 4 Ea","44885067","CDM","272","RC","A6234","HCPCS","","","facility","both","","","","4.15","4.15","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Bone Deep","44885069","CDM","983","RC","20225","HCPCS","","","facility","both","","","","1355.17","1355.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dressing Prisma Matrix 4.34 Sq","44885071","CDM","272","RC","A6022","HCPCS","","","facility","both","","","","804.1","804.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Superfcl Sft Tiss Bx Leg/Ankle","44885077","CDM","983","RC","27613","HCPCS","","","facility","both","","","","795.42","795.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Biopsy Leg/Ankle Deep","44885085","CDM","983","RC","27614","HCPCS","","","facility","both","","","","1799.67","1799.67","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Foreign Body Foot Subcu","44885093","CDM","983","RC","28190","HCPCS","","","facility","both","","","","810.82","810.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Rigid Tot Cont Leg Cast","44885101","CDM","983","RC","29445","HCPCS","","","facility","both","","","","391.21","391.21","","","","","","","","","","","","","Gross Charge Type: Standard"
"Splint Short Leg","44885119","CDM","983","RC","29515","HCPCS","","","facility","both","","","","216.78","216.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"Application Of Paste/Unna Boot","44885127","CDM","983","RC","29580","HCPCS","","","facility","both","","","","197.64","197.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Remove Gauntlet,Boot,Body Cast","44885143","CDM","983","RC","29700","HCPCS","","","facility","both","","","","194.08","194.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Upr/L Xtremity Art 2 Levels","44885150","CDM","983","RC","93922","HCPCS","","","facility","both","","","26","278.29","278.29","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Pf Upr/Lxtr Art Stdy 3+ Lvls","44885168","CDM","983","RC","93923","HCPCS","","","facility","both","","","26","431.88","431.88","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Hbot Md Attendance Per Session","44885176","CDM","983","RC","99183","HCPCS","","","facility","both","","","","313.96","313.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Ii","44885192","CDM","983","RC","99202","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iii","44885200","CDM","983","RC","99203","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl Iv","44885218","CDM","983","RC","99204","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit New Pt Lvl V","44885226","CDM","983","RC","99205","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl I","44885234","CDM","983","RC","99211","HCPCS","","","facility","both","","","","73.13","73.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Ii","44885242","CDM","983","RC","99212","HCPCS","","","facility","both","","","","139.24","139.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iii","44885259","CDM","983","RC","99213","HCPCS","","","facility","both","","","","226.01","226.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl Iv","44885267","CDM","983","RC","99214","HCPCS","","","facility","both","","","","326.32","326.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Visit Est Lvl V","44885275","CDM","983","RC","99215","HCPCS","","","facility","both","","","","436.18","436.18","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Ii","44885291","CDM","983","RC","99242","HCPCS","","","facility","both","","","","229.69","229.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iii","44885309","CDM","983","RC","99243","HCPCS","","","facility","both","","","","322.91","322.91","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl Iv","44885317","CDM","983","RC","99244","HCPCS","","","facility","both","","","","486.52","486.52","","","","","","","","","","","","","Gross Charge Type: Standard"
"Office Consult Lvl V","44885325","CDM","983","RC","99245","HCPCS","","","facility","both","","","","612.51","612.51","","","","","","","","","","","","","Gross Charge Type: Standard"
"Adaptec/Oil Emulsion Gauze 3X8","44885481","CDM","272","RC","","","","","facility","both","","","","90.31","90.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kerlex Wc","44885531","CDM","272","RC","A6446","HCPCS","","","facility","both","","","","2.24","2.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Culture Swabs","44885580","CDM","272","RC","","","","","facility","both","","","","116.62","116.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wnd Prep Trk/Arm/Leg 100Sq Cm","44885697","CDM","983","RC","15002","HCPCS","","","facility","both","","","","1076.06","1076.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wound Prep Addl 100 Cm","44885713","CDM","983","RC","15003","HCPCS","","","facility","both","","","","220.01","220.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wnd Prep 1St 100 Sq Cm/1% Ba","44885739","CDM","983","RC","15004","HCPCS","","","facility","both","","","","1225.58","1225.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surg Prep Wnd/Brn Addl Othr","44885754","CDM","983","RC","15005","HCPCS","","","facility","both","","","","361.27","361.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tympanometry","44885804","CDM","983","RC","92567","HCPCS","","","facility","both","","","","48.87","48.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"Glucose Fingerstick","44885820","CDM","300","RC","82962","HCPCS","","","facility","both","","","","45","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skn Grft F/N/Hf Ea Add 100Sqcm","44885896","CDM","983","RC","15278","HCPCS","","","facility","both","","","","282.63","282.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Lwr Xtr Vasc Stdy Bilat","44885946","CDM","983","RC","93924","HCPCS","","","facility","both","","","26","535.86","535.86","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Duplex Scan Of Le/Abg","44885962","CDM","983","RC","93925","HCPCS","","","facility","both","","","26","832.5","832.5","","","","","","","","","","","","","Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 26: Professional Component"
"Fac Fee Apply Multlay Comprs L","44886003","CDM","510","RC","29581","HCPCS","","","facility","both","","","","254","254","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Neg Press Wound Tx <50","44886011","CDM","510","RC","97605","HCPCS","","","facility","both","","","","310","310","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Neg Press Wound Tx >50","44886029","CDM","510","RC","97606","HCPCS","","","facility","both","","","","592","592","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Single Lesion","44886030","CDM","510","RC","11104","HCPCS","","","facility","both","","","","1211","1211","","","","","","","","","","","","","Gross Charge Type: Standard"
"Punch Bx Skin Ea Sep/Addl","44886031","CDM","510","RC","11105","HCPCS","","","facility","both","","","","1053","1053","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trim Nondystrophic Nails Any#","44886032","CDM","510","RC","11719","HCPCS","","","facility","both","","","","235","235","","","","","","","","","","","","","Gross Charge Type: Standard"
"Apply Multlay Comprs Lwr Leg","44886037","CDM","983","RC","29581","HCPCS","","","facility","both","","","","289.33","289.33","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wnd Tx <=50Sqcm","44886045","CDM","983","RC","97605","HCPCS","","","facility","both","","","","135.24","135.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neg Press Wound Tx >50Cm","44886053","CDM","983","RC","97606","HCPCS","","","facility","both","","","","160.45","160.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"2 Layer Compression System","44886061","CDM","623","RC","A6454","HCPCS","","","facility","both","","","","47.69","47.69","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue Add-On","44886087","CDM","510","RC","11045","HCPCS","","","facility","both","","","","330","330","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add-On","44886095","CDM","510","RC","11046","HCPCS","","","facility","both","","","","332","332","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Subq Tissue Add-On =<20 Sq","44886111","CDM","983","RC","11045","HCPCS","","","facility","both","","","","125.11","125.11","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Musc/Fascia Add  =<20Sq Cm","44886129","CDM","983","RC","11046","HCPCS","","","facility","both","","","","217.88","217.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Deb Bone Add-On =<20 Sq Cm","44886137","CDM","983","RC","11047","HCPCS","","","facility","both","","","","358.57","358.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Partial Amputation Of Toe","44886153","CDM","983","RC","28825","HCPCS","","","facility","both","","","","1680.45","1680.45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Amputate Metatarsal W Toe Sngl","44886179","CDM","983","RC","28810","HCPCS","","","facility","both","","","","1260.49","1260.49","","","","","","","","","","","","","Gross Charge Type: Standard"
"Pf Enzymatic Debridement","44886181","CDM","983","RC","97602","HCPCS","","","facility","both","","","","70.93","70.93","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Dress/Debrid P-Thick B","44886182","CDM","510","RC","16020","HCPCS","","","facility","both","","","","270","270","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Brn Sm","44886183","CDM","983","RC","16020","HCPCS","","","facility","both","","","","257.76","257.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debrid P-Thick Burn M","44886185","CDM","983","RC","16025","HCPCS","","","facility","both","","","","467.57","467.57","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dress/Debride Burn, Large","44886187","CDM","983","RC","16030","HCPCS","","","facility","both","","","","591.17","591.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sub Skin Grft T/A/L 1S","44886188","CDM","510","RC","15271","HCPCS","","","facility","both","","","","2891","2891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft Trnk/Arm/Leg","44886189","CDM","983","RC","15271","HCPCS","","","facility","both","","","","464.22","464.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sub Skin Grft T/A/L Ad","44886190","CDM","510","RC","15272","HCPCS","","","facility","both","","","","127","127","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft T/A/L Add 25 Sc","44886191","CDM","983","RC","15272","HCPCS","","","facility","both","","","","78.31","78.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sub Skin Grft Face/Sca","44886192","CDM","510","RC","15275","HCPCS","","","facility","both","","","","2891","2891","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft Face/Nk/Hf/G","44886193","CDM","983","RC","15275","HCPCS","","","facility","both","","","","483.09","483.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fac Fee Sub Skin Grft Face/Sca","44886194","CDM","510","RC","15276","HCPCS","","","facility","both","","","","128","128","","","","","","","","","","","","","Gross Charge Type: Standard"
"Skin Sub Graft F/N/Hf/Gnt Addl","44886195","CDM","983","RC","15276","HCPCS","","","facility","both","","","","100.82","100.82","","","","","","","","","","","","","Gross Charge Type: Standard"
"Debride Skin At Fx Site","44886197","CDM","983","RC","11010","HCPCS","","","facility","both","","","","1479.13","1479.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allevyn Foam 10.3X10.3 Cm","44886198","CDM","623","RC","A6213","HCPCS","","","facility","both","","","","7.94","7.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allevyn Sacrum 21.6X23 Cm","44886199","CDM","270","RC","A6214","HCPCS","","","facility","both","","","","25.76","25.76","","","","","","","","","","","","","Gross Charge Type: Standard"
"Allevyn Sacrum 17.2X17.5 Cm","44886200","CDM","270","RC","A6213","HCPCS","","","facility","both","","","","16.28","16.28","","","","","","","","","","","","","Gross Charge Type: Standard"
"Triad Hydrophillic Dressing","44886203","CDM","623","RC","A6240","HCPCS","","","facility","both","","","","46.77","46.77","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Silverlon Ag Contact 4""""X 5''""","44886204","CDM","272","RC","A6207","HCPCS","","","facility","both","","","","44.12","44.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix 4X4.5Cm Mesh","44886205","CDM","636","RC","Q4186","HCPCS","","","facility","both","","","","1941","1941","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Silverlon Ag Contact 5""""X 8''""","44886206","CDM","272","RC","A6207","HCPCS","","","facility","both","","","","88.2","88.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Dsg Alg W4Xl5In Hydrfbr Rect","44886207","CDM","272","RC","A6197","HCPCS","","","facility","both","","","","21.96","21.96","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix 18Mm Disc","44886209","CDM","278","RC","Q4186","HCPCS","","","facility","both","","","","1027.5","1027.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Epifix 2X2Cm","44886210","CDM","636","RC","Q4186","HCPCS","","","facility","both","","","","1495.97","1495.97","","","","","","","","","","","","","Gross Charge Type: Standard"
"Xtrasorb 6 X 9 ?????????","44886212","CDM","270","RC","A6253","HCPCS","","","facility","both","","","","16.85","16.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Drawtex 4"""" X 4"""" - A6196""","44886213","CDM","623","RC","A6196","HCPCS","","","facility","both","","","","23.66","23.66","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Drawtex 8"""" X 8"""" - A6198""","44886214","CDM","623","RC","A6198","HCPCS","","","facility","both","","","","45.58","45.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"""1/4"""" Amd Packing Strip - A6407""","44886215","CDM","623","RC","A6407","HCPCS","","","facility","both","","","","3.47","3.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Urgoclean Ag 2.5 X 2.5""""""","44886216","CDM","623","RC","A6196","HCPCS","","","facility","both","","","","38.08","38.08","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Urgoclean Ag 4 X 5""""""","44886217","CDM","623","RC","A6197","HCPCS","","","facility","both","","","","20.71","20.71","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Puracol Plus Ag 4.2 X 4.5""""""","44886218","CDM","623","RC","A6022","HCPCS","","","facility","both","","","","54.74","54.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Accuwrap Kit- 2 Layer","44886219","CDM","623","RC","A6441","HCPCS","","","facility","both","","","","31.36","31.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Ag 4 X4"""" Bordered""","44886220","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","15.06","15.06","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam 4 X4""""""","44886221","CDM","623","RC","A6209","HCPCS","","","facility","both","","","","9.12","9.12","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle 5 X5"""" Bordered""","44886222","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","10.46","10.46","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle 7 X7"""" Sacrum""","44886223","CDM","623","RC","A6213","HCPCS","","","facility","both","","","","21.09","21.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle 9 X9""""  Sacrum""","44886224","CDM","623","RC","A6213","HCPCS","","","facility","both","","","","25.58","25.58","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle 4 X4"""" Bordered""","44886225","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","7.61","7.61","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle 3 X3"""" Bordered""","44886226","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","7.16","7.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optifoam Gentle Ag 1.6X 2"""" Bor""","44886227","CDM","623","RC","A6212","HCPCS","","","facility","both","","","","17.8","17.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Therahoney Gel 0.5 Oz","44886228","CDM","623","RC","A6240","HCPCS","","","facility","both","","","","15.13","15.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Composite Gauze 4X8""""""","44886229","CDM","623","RC","A6219","HCPCS","","","facility","both","","","","2.8","2.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Composite Gauze 4 X14""""""","44886230","CDM","623","RC","A6220","HCPCS","","","facility","both","","","","3.78","3.78","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Oil Emulsion 3 X 8""""""","44886231","CDM","623","RC","A6223","HCPCS","","","facility","both","","","","3.6","3.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Iodoform Packing Strip 1/4""""""","44886232","CDM","623","RC","A6266","HCPCS","","","facility","both","","","","6.54","6.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Iodoform Packing Strip 1/2""""""","44886233","CDM","623","RC","A6266","HCPCS","","","facility","both","","","","7.48","7.48","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Iodoform Packing Strip 1""""""","44886234","CDM","623","RC","A6266","HCPCS","","","facility","both","","","","8.68","8.68","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Qwick 6.125 X8""""""","44886235","CDM","623","RC","A6198","HCPCS","","","facility","both","","","","34.87","34.87","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Qwick 4.25 X4""""""","44886236","CDM","623","RC","A6197","HCPCS","","","facility","both","","","","18.64","18.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optilock 4 X4""""""","44886237","CDM","623","RC","A6196","HCPCS","","","facility","both","","","","7.79","7.79","","","","","","","","","","","","","Gross Charge Type: Standard"
"""Optilock 4 X4""""""","44886238","CDM","623","RC","A6198","HCPCS","","","facility","both","","","","19.22","19.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Device Fx Thgtrp Fibertag Acl","45000412","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","808.5","808.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 12D 2-0 Truspan","45000419","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","984.8","984.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Button Fx 12Mm 8Mm Thgtrp Acl","45000420","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","346.5","346.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reportable Event Occurred","45000434","CDM","490","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Burn Rcvd Prior To Disch","45000435","CDM","490","RC","G8908","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bur Not Rcvd Prior To Disch","45000436","CDM","490","RC","G8909","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fall Exp Prior To Disch","45000438","CDM","490","RC","G8910","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fall Not Exp Prior To Disch","45000439","CDM","490","RC","G8911","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Site Pt Proc Impl Event","45000440","CDM","490","RC","G8912","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Site Pt Proc Impl Not Ex","45000441","CDM","490","RC","G8913","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Site","45000442","CDM","490","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Patient","45000443","CDM","490","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Procedure","45000444","CDM","490","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Wrong Implant","45000446","CDM","490","RC","","","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Adm To Hosp Proc Req At","45000447","CDM","490","RC","G8914","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Trans Adm To Hosp Proc Not Req","45000448","CDM","490","RC","G8915","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proph Antibiotic Not Ordered","45000449","CDM","490","RC","G8918","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Proph Antibiotic Ordered Init","45000450","CDM","490","RC","G8916","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Prophe Antiobiotic Ordered Not","45000451","CDM","490","RC","G8917","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Reportable Event Did Not Occur","45000453","CDM","490","RC","G8907","HCPCS","","","facility","both","","","","0.01","0.01","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens, Cataract Toric Alcon Sn6","45000455","CDM","276","RC","V2787","HCPCS","","","facility","both","","","","901.85","901.85","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Prtl Femur Sz.4 Biomet 4","45000456","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3084.9","3084.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Joint Device (Implantable)","45000457","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Prtl Articular Surf Sz.E","45000458","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2175","2175","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Screw Headed 3.0X24Mm Wr","45000461","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","701.4","701.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"K-Wire, Blunt 1.1X150Mm Wright","45000462","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","113","113","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Guid Btm Uln Shortng","45000463","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","459.9","459.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guide Uln Shortng L","45000464","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","880.5","880.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sut Novostitch Pro Sz 0 For","45000465","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1105.05","1105.05","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bolt Lok Uln Shortng Guid","45000466","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","204","204","","","","","","","","","","","","","Gross Charge Type: Standard"
"Peg Bne Fix Reduc Uln Shortng","45000467","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anch Sut Arthx Fibertak Rotr","45000468","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","814.27","814.27","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sft Tiss H3Mm Forehead","45000469","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","825.3","825.3","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bne 6 H Ulna Shortng Lp","45000470","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1433.25","1433.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Rad Dia20Mm +2Mm Offset","45000471","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3869.25","3869.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Rad Dia6.5Mm Cocr Std","45000472","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4581.94","4581.94","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sealant Fibrin 10Ml Hum Plsm","45000473","CDM","278","RC","C9250","HCPCS","","","facility","both","","","","804.34","804.34","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Brst 470Cc P6.1Cm","45000474","CDM","278","RC","L8600","HCPCS","","","facility","both","","","","1724.63","1724.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol 10 D +24.5 Diop Mod C","45000475","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","328.54","328.54","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol +7 Diop Mod C Bcnvx","45000476","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","319.73","319.73","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol 5 D +1 Diop Mod C","45000477","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","407.04","407.04","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post-Op Care 1 Hr","45000478","CDM","710","RC","","","","","facility","both","","","","5058","5058","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Compresn Kit 18 X 15 X 8","45000480","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3102.75","3102.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Btb Tightrope","45000481","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","446.25","446.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Anchor S-Tak Knotless","45000482","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","170","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Anchor Swivel Lock","45000483","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","168","168","","","","","","","","","","","","","Gross Charge Type: Standard"
"Impl, Anchor Fiber Tak Rc","45000484","CDM","278","RC","C1773","HCPCS","","","facility","both","","","","827.38","827.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Treatment Room 1 Hour","45000494","CDM","761","RC","","","","","facility","both","","","","1242","1242","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Evar 8Fr L60Mm Dia9Mm","45000495","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3609.9","3609.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Direct Referral Observation Ca","45000619","CDM","762","RC","G0379","HCPCS","","","facility","both","","","","597","597","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation 1St Hr","45000627","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","608","608","","","","","","","","","","","","","Gross Charge Type: Standard"
"Observation Addl Hr","45000635","CDM","762","RC","G0378","HCPCS","","","facility","both","","","","608","608","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Minilock Quick Anchor","45000703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","872","872","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Microfix Quick Anchor","45000704","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","898.16","898.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Iol Aspheric Acrysof Monofica","45000705","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","350.59","350.59","","","","","","","","","","","","","Gross Charge Type: Standard"
"Post Proc Care Ea 1/2 Hr","45001559","CDM","710","RC","","","","","facility","both","","","","1325","1325","","","","","","","","","","","","","Gross Charge Type: Standard"
"Place Cntrl Venous Cath Perc>5","45001682","CDM","761","RC","36569","HCPCS","","","facility","both","","","","4742","4742","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imp - Urolift Atc","45001683","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1496.25","1496.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Sft Tis Denovo Crtlg","45001685","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","6292.83","6292.83","","","","","","","","","","","","","Gross Charge Type: Standard"
"Mesh - Implantable","45001686","CDM","278","RC","C1781","HCPCS","","","facility","both","","","","309.75","309.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Unicort Dwl Allgrft 12Mm","45001687","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","945","945","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Dia12Mm Cann","45001688","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2295","2295","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Radl 20Mm Acumed Cntr Elb","45001689","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3803.63","3803.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Radl 10Mm Elb Strl","45001690","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3035.03","3035.03","","","","","","","","","","","","","Gross Charge Type: Standard"
"Shunt Glcm Ex-Prs 2.64Mm 50Um","45001691","CDM","278","RC","C1783","HCPCS","","","facility","both","","","","1439.95","1439.95","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Bn Cmnt 120Mm 11Ga","45001692","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","906.25","906.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 16Mm 2.5Mm","45001693","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","49.16","49.16","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clavicle Plate 6H/Lft/85Mm","45001694","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1188.42","1188.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 6Mm 14Mm Ss","45001695","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","47.02","47.02","","","","","","","","","","","","","Gross Charge Type: Standard"
"Grft Prstchd Non Irridtd","45001696","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","4856.25","4856.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Hum Tiss Dia13Mm Cann","45001697","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","1807.31","1807.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Tube Vent L12Mm Id1.14Mm Flng","45001698","CDM","278","RC","L8613","HCPCS","","","facility","both","","","","74.53","74.53","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stem Fngr Jt 4 L49.3Mm","45001699","CDM","278","RC","L8630","HCPCS","","","facility","both","","","","2494.5","2494.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Set Uret Stnt 7Fr L28Cm","45001701","CDM","278","RC","C1758","HCPCS","","","facility","both","","","","223.44","223.44","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L20Mm Dia9Mm Ant","45001702","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","567.63","567.63","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bne L20Mm Dia7Mm Ant","45001703","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","319.2","319.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"System Spnl Crd Stim Ipg Pt","45001704","CDM","278","RC","C1822","HCPCS","","","facility","both","","","","31500","31500","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrstm Blu 50Cm Nevro 5Mm","45001705","CDM","278","RC","C1778","HCPCS","","","facility","both","","","","1000","1000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stm Ld Nevro Anch N300","45001706","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","682.5","682.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrstm Nevro Tmplt Ipg2000","45001707","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","150","150","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr L20Mm Dia9Mm Ant","45001708","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","589.89","589.89","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bne Sub 0.5Cc Dbm Ptty","45001709","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","205.6","205.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Fngr Jt Sz 2 Flexspan","45001710","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3000.38","3000.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Putty Bne Grft Demin Bne Cont","45001711","CDM","278","RC","C1762","HCPCS","","","facility","both","","","","2587.5","2587.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bone Cement, Zimmer Palico","45001712","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1358.17","1358.17","","","","","","","","","","","","","Gross Charge Type: Standard"
"Filler Bn Void 1Cc Dbx Algrf","45001713","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","385.36","385.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bearing Tib Sz G Thk10Mm L Med","45001714","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1726.2","1726.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Baseplate Tib Persona G Kn Lt","45001715","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","1510.42","1510.42","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 6 Kn Lt Mdl Prt","45001716","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2756.25","2756.25","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2-0 Dia5.5Mm Blu","45001717","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","880","880","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut 25Deg L Crv Tight","45001718","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Passer Sut 25Deg L Crv Nit Wre","45001719","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","336","336","","","","","","","","","","","","","Gross Charge Type: Standard"
"Kit Nrstm Omnia Senza Ii Ipg","45001720","CDM","278","RC","C1882","HCPCS","","","facility","both","","","","33000","33000","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nerve L15Mm Dia2Mmp","45001721","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","2943.09","2943.09","","","","","","","","","","","","","Gross Charge Type: Standard"
"Connector Nrv L10Mm Dia2Mm","45001722","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","1984.5","1984.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bone L45 Dia4.5 Titanium","45001723","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Guidewire Orthopedic L150Mm Di","45001724","CDM","278","RC","C1769","HCPCS","","","facility","both","","","","45","45","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia3 Mini Foot Ank","45001725","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","367.5","367.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Sheath Interference L30 Dia9 3","45001726","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","779.1","779.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Interference L30 Dia8-10","45001727","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","753.9","753.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Noncdm Charge Record Medical S","45001728","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","292.36","292.36","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol +16.5 Diop Mod C","45001729","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","235.2","235.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol +21 Diop Mod C Bcnvx","45001730","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","235.2","235.2","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol 0 D +30 Dp Mod L","45001731","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","407.86","407.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 22Mm Ortholoc","45001732","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3.5Mm 30Mm Ortholoc","45001733","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","417.9","417.9","","","","","","","","","","","","","Gross Charge Type: Standard"
"Matrix Tiss Viaflow Plcnt","45001734","CDM","278","RC","Q4100","HCPCS","","","facility","both","","","","5742.19","5742.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Component Fem 4 Kn Rt Mdl Prt","45001735","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","3084.38","3084.38","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 2 Cp-2 Qanchr+ Pnlk","45001736","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1018.22","1018.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Iol Stableforce D+20.5","45001737","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","350.92","350.92","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 3Mm 24Mm Dart-Fire Ti","45001738","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","701.4","701.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Bn 4Mm 5Mm 1.35Mm 26Mm","45001739","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Cann 4.0Mm X 22Mm Short","45001740","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","343.64","343.64","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Hmdial 24Cm Hmfl 14.5","45001741","CDM","278","RC","C1750","HCPCS","","","facility","both","","","","415.8","415.8","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 4.75Mm Swivelock C","45001742","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","856.31","856.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Screw Intfr Bcmps 28Mm 10Mm","45001743","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","493.5","493.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5.5Mm 2 Sq Ft","45001744","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","746.24","746.24","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut Flt Fibertak Fbrwr","45001745","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","823.62","823.62","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Intraocular +23.5 Diopter","45001746","CDM","276","RC","V2632","HCPCS","","","facility","both","","","","295.47","295.47","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Ocular Dia13 Compress","45001747","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","458.74","458.74","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovascular L60 Dia9 8F","45001748","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3543.75","3543.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip 235Cm Intnl Rsl Scrlk","45001749","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","252","252","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip Lgt Rsl 360 235Cm 2.8Mm","45001750","CDM","278","RC","C1889","HCPCS","","","facility","both","","","","464.7","464.7","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate 0Mm Spc Ft Recon Sys","45001751","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","3780","3780","","","","","","","","","","","","","Gross Charge Type: Standard"
"Hemostat Abs Bionert Arista","45001753","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","210","210","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 4 Hole Left Distal","45001754","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1422.22","1422.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Fixation Proximal Interpha","45001755","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","1871.1","1871.1","","","","","","","","","","","","","Gross Charge Type: Standard"
"Clip 16Mm 230Cm Intnl Instinct","45001756","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","489.72","489.72","","","","","","","","","","","","","Gross Charge Type: Standard"
"Ligator Endoscopic 6 Shooter S","45001757","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","878.22","878.22","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lead, Neurostim Test Kit","45001758","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Nrstm 50Cm Nevro 5Mm Spc","45001759","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","2250","2250","","","","","","","","","","","","","Gross Charge Type: Standard"
"Neurostimulator Lead L70 5","45001760","CDM","278","RC","C1897","HCPCS","","","facility","both","","","","1575","1575","","","","","","","","","","","","","Gross Charge Type: Standard"
"Implant Breast 355Cc Dia12.1Cm","45001761","CDM","278","RC","C1789","HCPCS","","","facility","both","","","","1567.13","1567.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Esph 23Mm 18.5Fr 10Cm 78","45001762","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","2812.5","2812.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Fix Otsc","45001763","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","898.5","898.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Pncr 15Mm 24Mm 10Mm 146","45001765","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","7926.19","7926.19","","","","","","","","","","","","","Gross Charge Type: Standard"
"Head Radl 10Mm 22Mm 6.5Mm Elip","45001766","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","4393.6","4393.6","","","","","","","","","","","","","Gross Charge Type: Standard"
"Cannula Bne Cem 11Ga L200Mm","45001767","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","889.88","889.88","","","","","","","","","","","","","Gross Charge Type: Standard"
"Stent Ureteral 8Fr L28Cm Percu","45001768","CDM","278","RC","C2617","HCPCS","","","facility","both","","","","295.32","295.32","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Suture Peek Swivelock T","45001769","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","2718.75","2718.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 7Fr Shaft","45001770","CDM","272","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Intraocular 18.0 Diopter","45001771","CDM","276","RC","V2787","HCPCS","","","facility","both","","","","281.4","281.4","","","","","","","","","","","","","Gross Charge Type: Standard"
"Imp-Urolift 4 Try Dlv","45001772","CDM","278","RC","L8699","HCPCS","","","facility","both","","","","1417.5","1417.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protct Nrv L40Mm Dia5Mm","45001773","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","3507","3507","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Intraocular +21.5 Diopter","45001774","CDM","276","RC","V2788","HCPCS","","","facility","both","","","","1567.13","1567.13","","","","","","","","","","","","","Gross Charge Type: Standard"
"Surface Articular Femorl 10-11","45001775","CDM","278","RC","C1776","HCPCS","","","facility","both","","","","2049.86","2049.86","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 6 75 4","45001776","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Catheter Angioplasty 6 75 .035","45001777","CDM","278","RC","C1725","HCPCS","","","facility","both","","","","315","315","","","","","","","","","","","","","Gross Charge Type: Standard"
"Lens Intraocular +16.5 Dptr 13","45001778","CDM","276","RC","V2630","HCPCS","","","facility","both","","","","170","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Bone Substitute Dia11Mm","45001779","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","1807.31","1807.31","","","","","","","","","","","","","Gross Charge Type: Standard"
"Anchor Sut 5Mm Pk Knotless","45001780","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","787.5","787.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Graft Endovascular L60 D10 8","45001781","CDM","278","RC","C1874","HCPCS","","","facility","both","","","","3543.75","3543.75","","","","","","","","","","","","","Gross Charge Type: Standard"
"Protector Nerve L40 D7 Porcine","45001782","CDM","278","RC","C1763","HCPCS","","","facility","both","","","","3407.5","3407.5","","","","","","","","","","","","","Gross Charge Type: Standard"
"Plate Bone 5 Hole Right Distal","45001783","CDM","278","RC","C1713","HCPCS","","","facility","both","","","","975","975","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia2.5Mm Calibrated","45001784","CDM","272","RC","A4649","HCPCS","","","facility","both","","","","170","170","","","","","","","","","","","","","Gross Charge Type: Standard"
"Bit Drill Dia1.8Mm With Add","45001785","CDM","272","RC","A4649","HCPCS","","","facility","both","",